AIDS

Baroness Northover: asked Her Majesty's Government:
	What further action they propose to take in the light of the increasing severity of the AIDS epidemic.

Baroness Amos: My Lords, my right honourable friend the Prime Minister launched the UK's Call for Action on HIV/AIDS a year ago. We will spend at least £1.5 billion over the next three years and will make AIDS the centrepiece of our G8 and European Union presidencies next year.

Baroness Northover: My Lords, I thank the noble Baroness for that reply and I welcome what the Government and, in particular, what she and the Secretary of State have done. But does the noble Baroness agree that far greater international efforts will be required, given that AIDS has killed millions in Africa, is spreading rapidly across Asia and is rising at its fastest in eastern Europe? On a more positive note, UK patients have lived with AIDS for more than 20 years because of drug treatment. Can the noble Baroness tell us what efforts are now being made to speed up the approval, production and distribution of cheap medicines to help to stem the disaster elsewhere?

Baroness Amos: My Lords, I agree with the noble Baroness, Lady Northover, about the importance of co-ordinated international efforts. I also agree with her about the scale of infection. World Health Organisation pre-qualification was mentioned on the Radio 4 "Today" programme this morning. Perhaps I may explain to noble Lords that developing countries do not have the expertise or a regulatory regime in relation to these drugs, and so the WHO carries out the pre-screening, which means that the country in question can then endorse the decision. There has been a problem with some of the paperwork but not with the drugs themselves. I am pleased to be able to advise the House that that problem has now been resolved in two cases, and we shall continue to work with the WHO so that it can be resolved as a matter of urgency.

Baroness Whitaker: My Lords, I am sure that nevertheless the Government should be congratulated on their funding for AIDS. But does my noble friend agree with the report of the Africa All-Party Parliamentary Group on AIDS? Does she agree that its recommendations should be implemented—in particular, the one that says that DfID should lead a coherent attempt on the part of all UK government departments to support efforts to fight AIDS?

Baroness Amos: My Lords, I agree with that recommendation. Indeed, my noble friend may recall that when we launched our strategy in July last year, that was one of the recommendations. DfID works very closely with the Department of Health, the DTI and the FCO. An informal working party is due to be set up and will meet early in the new year.

Lord Elton: My Lords, does the substantive answer that the noble Baroness has just given mean that the news on the "Today" programme—that is, that a large proportion of the medicines intended to curb AIDS are substandard and cannot be used—was misleading or was she referring to some other débâcle?

Baroness Amos: My Lords, I was referring to that report, which was misleading in the sense that the WHO needs documentation which allows it to look at the drugs on behalf of developing countries. Some of that documentation, but not the drugs, has been faulty. So some of the companies have withdrawn the documentation, they have looked at it again and have resubmitted it. In two cases, the documentation has now been passed; in other cases, we are waiting for the resubmission of the documentation.

Baroness Greengross: My Lords, the Minister will be aware that women now make up almost half of all AIDS victims. But is she also aware that it is usually women—often grandparents and sometimes, post-conflict, very young widows—who can be punitively treated and who are left to pick up the pieces of their community as well as their family? What more can we do to help them, especially with their caring roles, often for young children?

Baroness Amos: My Lords, the noble Baroness is quite right. In fact, when I was preparing for this Question, I was staggered to find that in Zimbabwe, Zambia and South Africa, 75 per cent of all young people infected with HIV/AIDS are girls. So this is a huge burden on families and on those young women, and of course there are many reasons for that. We are doing a number of different things. In Pakistan, we funded a family protection project and, in Malawi, we are funding a victim support unit that provides advice and counselling to women. But we also have to work with men because many women are getting these diseases from men who, for example, have several partners or the women are involved in prostitution. So it is important that men engage in safe sex as well.

Lord McColl of Dulwich: My Lords, as the incidence of AIDS has been reduced in Uganda from 31 per cent to 5 per cent by adopting the policy of ABC—abstinence, be faithful in marriage and condoms—through a comprehensive approach, why do the Government continue to say that abstinence does not work? If the Government go on saying that, do they not need a tutorial on the facts of life?

Baroness Amos: My Lords, it is really important to look at the context. In Uganda, ABC with leadership and very good awareness-raising has been important. We have said absolutely clearly that abstinence-only programmes will not work. All the research demonstrates that. When young people are already engaged in sexual activity, there is very little point then telling them to abstain. It is a matter of looking at the issue in the round and coming up with solutions that are appropriate for that particular situation.

Lord Hylton: My Lords—

Baroness Farrington of Ribbleton: My Lords, it is time to move to the next Question. Due to the power failure, the clock stopped; so Questions should finish at 25 minutes on the clock instead of 30.

Disability Benefits

Lord Ashley of Stoke: asked Her Majesty's Government:
	Whether they are satisfied with the take-up of disability benefits.

Baroness Hollis of Heigham: My Lords, broadly yes, for disability living allowance and attendance allowance benefits which help people with the extra cost of disability. Successful DLA claims have increased by 25 per cent in the past five years. However, the answer is broadly no for incapacity benefit when people linger too long on an income replacement benefit when they can and wish to return to work. With their support, we are seeking to address that with our Pathways to Work project.

Lord Ashley of Stoke: My Lords, I thank my noble friend for that response. I am well aware of the welcome steps taken by the Government to increase take-up. Does she agree that so far those steps have failed to resolve the problem? The fact that the take-up of some benefits is only about 40 per cent is a clear indication of that. It is also a clear indication of disabled people not refusing the money to which they are entitled. Millions of pounds are not being claimed.
	In my view, the best way to resolve this is for the Government to give a commitment that they will approach all disabled people and inform them of their rights to benefit and urge them to apply. That is already being done on a small scale by various local authorities and public utilities in relation to other issues. Will the Government begin to do that and perhaps solve this awful problem?

Baroness Hollis of Heigham: My Lords, I am very happy to consider the suggestion of my noble friend in further detail. Most benefits have take-up ranges; for example, income support is 90 per cent plus, and so on. The difficulty with the disability living allowance is that there is no straightforward read-across from the degree of disability to the degree of employability or the need for DLA. Although we know who is disabled, one can determine eligibility for disability living allowance only by a one-to-one personal interview, filling in the forms and so on. We are not sure how many people are under-claiming. I absolutely agree with my noble friend that it is important that everyone who is entitled to the benefits should access them. We are working on that very extensively.

Earl Ferrers: My Lords, will the noble Baroness do her best to simplify the forms? At the moment the forms are the size of a book, the questions are intrusive and incomprehensible and the whole procedure is frightening.

Baroness Hollis of Heigham: My Lords, we have reduced the pages of the attendance allowance form, which is for older people, from 38 to about 19.

Noble Lords: Oh!

Baroness Hollis of Heigham: Yes, my Lords. The forms are in big print. One page is simply for identifying the applicant's family; the second page is for a person who is filling in the form for someone else, as is the third page; the fourth page asks for illnesses and disabilities; the fifth page asks about the treatment being received; and the next page asks why the claim is being made. These are high-value benefits and people are asked to fill in a space such as this on these rather big-print forms. It is not surprising that the information is needed. We need to be able to determine that up to £100 a week properly goes to those who need it. We are also seeking to simplify the forms for the disability living allowance.
	We have to ensure that people not only claim the money, but that the right people receive it. These are high-value benefits. We also have helplines for people; leaflets in eight or 10 ethnic minority languages; and forms that are prepopulated in the sense that they can be completed over the telephone and signed afterwards. We are genuinely seeking to ensure that people who are entitled to the money claim it and receive it. However, we cannot simply say, "We feel sorry for you; have some money". There has to be a proper audit trail for the money. It is a high-value benefit.

Lord Higgins: My Lords, I think that reply will be at least 19 pages in Hansard. In view of the widespread computer problem in the Department for Work and Pensions, will the computer dealing with disability benefit claims and payments be satisfactory? What steps are being taken to ensure that the system will be adequate after the passage of the Disability Discrimination Bill?

Baroness Hollis of Heigham: My Lords, I do not understand the connection with the second question. On the first question, the computer is certainly adequate for purpose and has not been affected. The Disability Discrimination Bill does not have anything to do with benefit claims, so I do not see the point of the noble Lord's second question.

Lord Addington: My Lords, will the Minister give the House some inkling of the Government's research into the low take-up of benefit? Will that enable claimants to access anything else available to them in other sections of society, which I am afraid does bring us back to the new Bill and the previous legislation?

Baroness Hollis of Heigham: My Lords, is the noble Lord suggesting that what matters is that the benefit is the passport to other benefits? Is that the push of his question?

Lord Addington: My Lords, it is the access of benefits to the whole of society.

Baroness Hollis of Heigham: My Lords, I am probably being slow today but I do not understand the import of that question. It is clear that if somebody has DLA they are more likely successfully to hold down a job by virtue of the extra support and so on. Access to benefits is independent of civil rights. The noble Lord's question is more appropriately associated with questions on civil rights, which will be reflected in the Bill that we shall discuss on Monday.

Farming

Baroness Byford: asked Her Majesty's Government:
	Whether the draft European Union regulations on the circumstances in which farmers may or may not perform mechanical operations will be enforced on a national, regional or local basis.

Lord Whitty: My Lords, from 2005, farmers must keep their land in good agricultural and environmental condition (GAEC) if they claim a subsidy under CAP direct payment schemes, including the single payment.
	Under EU framework rules, GAEC must cover standards to protect soils, including to maintain soil structure. In England, this measure restricts unnecessary mechanical field operations on waterlogged soil. Agriculture is a devolved matter within the UK, so, within that framework, the regulations are decided separately by each country.

Baroness Byford: My Lords, does not the Minister agree that the proposals in these draft regulations in regard to waterlogged soil are total madness—that the Secretary of State will be the one to decide when a farmer can or cannot work on his crops? My Question asked whether decisions will be made on a national or regional basis. Even in one field on a farm the quality of the soil and its waterloggedness can vary. Will the Minister tell the House whether—and, if so, why—the Government are going to support this completely mad suggestion?

Lord Whitty: My Lords, I regret that the noble Baroness regards this provision as mad. We are concerned about the quality of the soil. If "good agricultural and environmental condition" means anything, it must mean respect for the soil and how we manage it. This regulation does not come out of the blue; it is a condition for getting a very large payment from the taxpayer via the European Union. The system will replace a lot of the bureaucracy which pre-existed it under 11 different schemes for claiming EU payments. The question of whether you should use heavy machinery in a waterlogged field is clearly a part of how you treat the soil. Therefore, there should be some restriction on so doing.

Lord Dixon-Smith: My Lords, is the Minister aware that a single farm can have some soil where you can start work with no difficulty the morning after a day's heavy rain, and other soil where you cannot work for a week after a day's heavy rain? There are times when you have to do so when the soil is waterlogged or lose the whole crop.
	I think that these regulations from Brussels put the Minister's right honourable friend at risk of being invited to play God.

Lord Whitty: My Lords, the specific English interpretation of the regulations from Brussels—there are similar arrangements in Scotland, Wales and Northern Ireland—is to protect the soil. There are exemptions in relation to bringing in heavy mechanical equipment if by failing to so do, even in a waterlogged situation, you lose the crop or you breach contractual arrangements.
	Another exemption, to which I assume the noble Lord, Lord Dixon-Smith, refers, is that if there has been particularly heavy rain and there is no ability to do anything about it, we are prepared to have an additional exemption in England which is determined by the department and, ultimately, by the Secretary of State. That is not playing God; that is being sensible in interpreting how effective and how restrictive we should be. The basic point of the regulations is that we do not want heavy machinery used unnecessarily in waterlogged conditions.

Lord Livsey of Talgarth: My Lords, does not the Minister agree that this refers to good husbandry, which is very important in establishing an efficient agricultural system? Can he assure me that Defra will avoid excessively gold-plating this particular regulation? Otherwise, we could end up, as usual, following the rules of cricket with the rest of Europe following the rules of baseball, perhaps.

Lord Whitty: My Lords, of course to some extent cricket also suffers from waterlogging. As far as I know, Brussels has not made any rules about it. The noble Lord is quite right that this is elementary husbandry for ensuring that land is kept in good agricultural condition. It must be applied sensibly. This is part of the minimum standard for looking after soil. It will be applied sensibly, in terms of the exemptions to which I have referred and the sensitivity of the enforcement.

Lord Northbourne: My Lords, will the noble Lord assure the House that, in applying these rules sensibly, the people making the decisions will have experience in agriculture and in soil management?

Noble Lords: Oh!

Lord Northbourne: My Lords, it seems that we have some disagreement from the opposition Benches. These people should also have experience in the cultivation and working of soil.

Lord Whitty: My Lords, the enforcers of these regulations in general will be the officials of the Rural Payments Agency, who of course are very experienced in all aspects of agriculture.

The Duke of Montrose: My Lords, perhaps the Minister could answer the first part of the question of my noble friend Lady Byford. Do the Government have any view on whether these regulations will be brought in on a parish, district or county basis? How will they distinguish which areas are considered to be waterlogged? I gather that at one time these regulations were interpreted as applying only in winter. Does the Minister envisage that they could apply all year round?

Lord Whitty: My Lords, there is no seasonal distinction. Clearly, it rains more in some seasons and in some parts of the country than in others. The regulations are national in the sense that they are English. There are Scottish, Welsh and Northern Irish regulations which are broadly similar. In fact, the English ones probably have rather more exemptions than the others, possibly because it rains more in those countries.
	The regulations will be applied by local officers as part of their general approach as to whether the farmer is keeping the land in good agricultural and environmental condition, which is the basic European standard. It will be subject to information on rainfall, but based primarily on the condition of the soil.

The Countess of Mar: My Lords, the Minister did not answer the question of the noble Baroness, Lady Byford, about different fields having different conditions. On our farm we have a field which we call "hell-hole" because most of the year it is such a swine to get anything on or off it. It is wet and soggy at one end and dry and dusty at the top end. How will the legislation be policed? What penalties will there be for farmers who do not obey the rules?

Lord Whitty: My Lords, as part of the assessment of whether good agricultural and environmental standards have been met, local officers will need to take into account the topography, the nature of the soil and what the farmer is doing in general to keep the land in good condition. As I say, they will be expert people dealing with such areas.
	As far as concerns sanctions, I think that the House should look at the matter the other way around. This is a very basic condition for the payment of a substantial amount of money to farmers. The total cost of compliance with all matters, including this, amounts to around 1 to 2 per cent of the total benefit of the subsidy. That seems a not unreasonable condition. Part of that compliance must include keeping the soil in good condition and therefore avoiding unnecessary machinery going into waterlogged fields.

Lord Mackie of Benshie: My Lords—

Earl Ferrers: My Lords, is this not bureaucracy gone mad? What makes the noble Lord, Lord Whitty, think that the officials of the Rural Payments Agency will know more about the mechanical conditions of the soil than the farmer who actually runs the farm?

Lord Whitty: My Lords, it is not bureaucracy gone mad; it is ensuring that the farmer operates in a way that gets the support of society as a whole and does the basic job of keeping the land in good condition. Regrettably, it is true that on occasions some farmers have not taken very good care of their soil. Therefore, the regulations should at least give them a nudge that if they continue operating in a way which destroys the quality of the soil, the sanction is that their payment could be docked. But that is the ultimate sanction. Primarily, this provision ensures good husbandry, good condition of the soil and therefore better farming and better landscape.

Hearing Aids

Baroness Howe of Idlicote: asked Her Majesty's Government:
	What plans they have to extend the public/private partnership between the National Health Service and private hearing aid dispensers so that more private sector companies can help audiology departments to reduce waiting times for digital hearing aids.

Lord Warner: My Lords, the existing contract with two private companies was established following a public tendering process and runs until October 2005, at which point it will be open to review. The current public/private partnership is proving very successful, with more than 12,000 patients already off the NHS waiting list and more than 50,000 set to benefit by April 2006. Both companies have the capacity to see more patients if local NHS trusts choose to commission additional services, although there are currently no plans to extend the partnership.

Baroness Howe of Idlicote: My Lords, I thank the Minister for that reply and, in passing, congratulate the Government and the Royal National Institute for Deaf People on the tremendous efforts that they have already made to get digital hearing aids to NHS patients. However, is not the Minister a little disturbed by the recent survey by the British Society of Hearing Aid Audiologists, which reports an average delay of 46 weeks between a GP referral and the actual fitting of a hearing aid? In some parts of the country, the delay is as long as four years.
	As we now know from the RNID that the quality of life of 3 million to 4 million people could be considerably enhanced by digital hearing aids—I believe that there have been signs of up to 41 per cent improving in hearing—is there not a strong case for involving many more than the two private companies which employ registered hearing aid dispensers to speed up the process for NHS patients?

Lord Warner: My Lords, I do not think that that is necessary. As I said in my Answer, the companies have the capacity to see more patients if local NHS trusts choose to commission additional services. So there is no lack of capacity in the system to supply. This Government were the first to address the fact that NHS audiology was suffering from outdated technology and long waiting times. We are to some extent the victims of our own success by introducing digital hearing aids, which were never previously available.

Baroness Greengross: My Lords, will the Government monitor waiting times after next year? After all, older people, who form the majority of hearing aid users, do not have time to wait for up to four years. It would be very good if we knew how that monitoring is to be carried out.

Lord Warner: My Lords, we intend, as we do across the NHS, to return that money to local PCTs. It will then be for NHS PCTs, which, after all, are now responsible for about 80 per cent of expenditure on the NHS, to ensure that their services meet the needs of their communities.

Lord Ashley of Stoke: My Lords, I declare an interest as the president of the RNID. Does not my noble friend agree that the scheme compiled by the RNID and his department is a tremendous success? So far, it has given 250,000 deaf and hard of hearing people a digital hearing aid free, whereas a short while ago they were extremely expensive. That is a great accomplishment but, as we have already heard, there are delays all over the country, bottlenecks and long queues of people. In my view, the only way to resolve that problem is for the Government to make the scheme a much higher priority, allocate more resources and more skilled audiologists. Can my noble friend help on that?

Lord Warner: My Lords, I am grateful for my noble friend's remarks. He is quite right: the scheme has been a huge success, which is down to the work that we have accomplished in partnership with the RNID, to which I pay great tribute, and is as a result of the extra £125 million that we have invested in the area since the modernising hearing aid service started in September 2000. We are working with the RNID and others to expand NHS audiology posts, of which we acknowledge that we need more. However, as I said, it is down to PCTs, which are supposed to consider the needs of their local communities, to determine their priorities and to put resources into those which meet the needs of their local communities.

Baroness Neuberger: My Lords, given that the Minister has just said that it is down to local PCTs, can he say how many PCTs have taken advantage of the PPP so far; how many more patients have been treated as a result; and, indeed—although this may be a guess—how many PCTs have indicated their desire to participate in the PPP in future and the extent to which the Government may encourage PCTs to do so?

Lord Warner: My Lords, I can answer the first question: the latest figure that I have is that about 75 NHS trusts have committed themselves to participate in the public/private partnership, which represents almost 50 per cent of the NHS audiology departments in England. I do not have information on how many more have expressed an interest or are moving towards participating in the partnership, but we are putting a lot more money into the area. As my noble friend Lord Ashley said, about 250,000 people have already benefited from the modernising hearing aid service with new digital hearing aids.

Lord Elton: My Lords—

Lord St John of Bletso: My Lords, while welcoming the partnership—

Baroness Farrington of Ribbleton: Order.

Lord Elton: My Lords, I believe that it is our turn.
	The more people who benefit and the more swiftly they do so, which is welcome, the more unfair it is to those who do not. What does the Minister propose to do about those who, scandalously, have to wait for four years?

Lord Warner: Well, my Lords, under this Government, some have managed to get digital hearing aids, which is more than was possible under the previous administration. I remind the noble Lord that digital hearing aids were then available only privately for up to £2,500 per aid. By the PPP, we have knocked the price down to as low as £55. I do not think that we need too many lectures from the noble Lord.

Lord St John of Bletso: My Lords—

Business of the House: Debates this Day

Baroness Amos: My Lords, I beg to move the Motion standing in my name on the Order Paper.
	Moved, That the debates on the Motions in the names of the Baroness Gardner of Parkes and the Lord Hanningfield set down for today shall each be limited to two and a half hours.—(Baroness Amos.)

On Question, Motion agreed to.

Constitution Committee

House Committee

Science and Technology

Deputy Chairmen of Committees

Lord Brabazon of Tara: My Lords, I beg to move the four Motions standing in my name on the Order Paper.
	Constitution Committee
	Moved, That a Select Committee be appointed to examine the constitutional implications of all public Bills coming before the House; and to keep under review the operation of the constitution;
	That, as proposed by the Committee of Selection, the following Lords be named of the committee:
	L. Acton, V. Bledisloe, L. Carter, L. Elton, B. Gould of Potternewton, B. Hayman, L. Holme of Cheltenham (Chairman), L. Lang of Monkton , L. MacGregor of Pulham Market, B. O'Cathain, E. Sandwich, L. Smith of Clifton;
	That the committee have power to appoint specialist advisers;
	That the committee have power to adjourn from place to place;
	That the committee have leave to report from time to time;
	That the minutes of evidence taken before the Constitution Committee in the last Session of Parliament be referred to the committee;
	That the minutes of evidence taken before the committee from time to time shall, if the committee think fit, be printed.
	House Committee
	Moved, That a Select Committee be appointed to supervise the general administration of the House and guide the work of the Management Board; to agree the annual Estimates, Supplementary Estimates and the three-year spending forecasts; to approve the House of Lords Annual Report; and to approve changes in employment policy;
	That, as proposed by the Committee of Selection, the following Lords together with the Chairman of Committees be named of the committee;
	B. Amos (Lord President), L. Barnett, L. Burlison, L. Hunt of Wirral, L. Lloyd of Berwick, L. McNally, L. Renfrew of Kaimsthorn, L. Sharman, L. Strathclyde, L. Williamson of Horton;
	That the committee have leave to report from time to time;
	That the reports of the Select Committee from time to time shall be printed, notwithstanding any adjournment of the House.
	Science and Technology
	Moved, That a Select Committee be appointed to consider science and technology and that, as proposed by the Committee of Selection, the following Lords be named of the Select Committee:
	L. Broers (Chairman), B. Finlay of Llandaff, L. Mitchell, L. Patel, L. Paul, B. Perry of Southwark, B. Platt of Writtle, B. Sharp of Guildford, L. Soulsby of Swaffham Prior, L. Sutherland of Houndwood, L. Taverne, L. Turnberg, L. Winston, L. Young of Graffham;
	That the committee have power to appoint sub-committees and that the committee have power to appoint the chairmen of sub-committees;
	That the committee have power to co-opt any Lord for the purposes of serving on the committee or any sub-committee;
	That the committee have leave to report from time to time;
	That the committee and any sub-committee have power to adjourn from place to place;
	That the committee and any sub-committee have power to appoint specialist advisers;
	That the minutes of evidence taken before the Science and Technology Committee or any sub-committee in the last Session of Parliament be referred to the committee;
	That the minutes of evidence taken before the committee from time to time shall, if the committee think fit, be printed.
	Deputy Chairmen of Committees
	Moved, That, as proposed by the Committee of Selection, the following Lords be appointed as the panel of Lords to act as Deputy Chairmen of Committees for this Session:
	V. Allenby of Megiddo, L. Ampthill, L. Boston of Faversham, L. Brougham and Vaux, L. Carter, L. Cope of Berkeley, L. Elton, B. Fookes, L. Geddes, B. Gould of Potternewton, L. Grocott, L. Haskel, B. Hooper, B. Lockwood , L. Lyell, C. Mar, B. Pitkeathley, B. Ramsay of Cartvale, V. Simon, B. Thomas of Walliswood, L. Tordoff, B. Turner of Camden, V. Ullswater.—(The Chairman of Committees.)

On Question, Motion agreed to.

Hospital-acquired Infections

Baroness Gardner of Parkes: rose to call attention to government health policies, with particular reference to initiatives designed to reduce hospital-acquired infections; and to move for Papers.
	My Lords, "hospitalism" is an interesting word, and one that I had never heard until I looked up the biography of Joseph Lister. This debate today could well be called a debate on hospitalism, the name applied in the mid-19th century to often fatal post-operative infection. "The operation was a success, but the patient died", was the famous saying. Now we have hospital-acquired infection.
	In my days as a dental student, we heard much of Lister, known as the father of antiseptic surgery. I was not aware that he was a Member of your Lordships' House, taking the title Lord Lister of Lyme Regis in 1899. Lister noticed that many people survived the trauma of an operation but died shortly after of what was then known as "ward fever".
	Work on ward cleanliness and the link between germs and health was being studied in Hungary, where Dr Semmelweiss argued that if a doctor went from one patient to another without clean hands, the doctor could pass on to the next visited patient a potentially life-threatening disease. He insisted that doctors washed their hands in disinfectant. Deaths of his patients fell from 12 per cent to just 1 per cent, but he was an isolated pioneer and his findings were ignored. Sadly, he himself died of blood poisoning in 1865.
	Lister was influenced by his work and that of Louis Pasteur, whose work established the existence of bacteria at about that time. In 1865, Lister was convinced that microbes carried in the air caused diseases to be spread in wards. By disinfecting the air during his operations, the death rate fell from over 45 per cent to 15 per cent.
	It is interesting to hear that similar ideas are now being suggested to reduce the spread of MRSA. At lunchtime I saw the announcement on television of just such a machine in modern form, which, the Secretary of State says, will solve the problem completely. Lister introduced strict antiseptic procedures into hospital routine. He washed his hands before operations and cleaned the instruments and dressings. That was when there was a great increase in medical provision, higher standards of nursing, larger hospitals and, with the introduction of anaesthetics, many more surgical interventions. The need to keep germs at bay was clear.
	When I trained as a dentist, instruments were usually sterilised by boiling, although some practitioners continue simply to soak their instruments in an antiseptic solution. Injections of local anaesthetic were made by dropping tablets into sterile water, the solution then being drawn up into the reusable syringe and needle. Those were normal procedures. As hepatitis B became a risk, boiling was no longer effective, and dentists had to move to sealed sterile injections and new disposable needles. Autoclaving became the normal form of sterilisation for instruments and dressings. New infective organisms required new precautions.
	Penicillin, the miracle drug, widely used by doctors and dentists, was originally effective against staphylococcus aureus infection. In the 1950s, strains of staphylococcus aureus became resistant to penicillin and by the 1960s strains were developing resistance to a stronger antibiotic, methicillin. This resistant strain, methicillin resistant staphylococcus aureus, is now commonly known as MRSA. Almost everyone knows or has heard of someone who has suffered MRSA infection. The stories are harrowing and the outcome too often fatal. The only treatment now is with an even more powerful antibiotic, which has unfortunate renal side effects. Resistance to that, VRSA, is now being reported.
	The overuse of antibiotics has been one of the causes of the MRSA problem. Patients demand antibiotics from practitioners, even when they are told that they will have no effect on their condition. Education in those matters of patients and practitioners is very important. I am concerned by the commercial promotion at present of all sorts of disinfectants for home use, in washing-up liquid, toilet cleaners, even hand washes. There is a risk that we will destroy the normal immunity that people develop as they contact organisms in everyday life. Homes are not the same as hospitals.
	MRSA is now endemic in many UK hospitals. MRSA cases have increased by 600 per cent in the past decade. In 2002, it was the listed cause of 800 deaths, although it was believed that there were probably nearer 5,000 cases. Some London hospitals have seven times worse rates than those in the least affected parts of England.
	A family friend, living until recently in Russia, decided to return to England for the birth of her baby. It was an unlucky decision, as she contracted MRSA. The hospital was dirty. She was put into isolation, in a single room with its own bathroom, the floor of which was dirty and stained with blood, not hers. She was extremely ill and separated from the baby for some weeks. Eventually she recovered, but it made her wonder why she had thought England could offer better care than Russia.
	Some of the large London teaching hospitals are disadvantaged by the fact that they are tertiary referral centres and patients are sent to them from a wide area. Smaller hospitals cannot handle cases and, concerned by the seriousness of the patient's condition, send them up the line for diagnosis and treatment. As there is a shortage of single rooms where referred cases can be isolated, once a case is diagnosed as MRSA it can necessitate the closure of a whole ward. Tables showing the hospitals with high MRSA infection rates do not make allowance for the fact that many may be referrals.
	Medicine has continued to make great progress, but harmful organisms have, too, and dealing with those is the challenge today. Mutation of organisms is a major problem, as we know from the constantly changing HIV virus, for which there is treatment but no cure. There have been many cases of haemophiliacs contracting transfusion-transmitted hepatitis B and C and HIV infections through defective blood products.
	The latest risk is of transmission of new variant Creutzfeld-Jacob disease (vCJD). A number of patients are known to be at risk, as some blood donors developed vCJD and died of it after giving blood. Two recipients of that blood have now developed vCJD. The blood products were used particularly for haemophilia cases. An estimated 6,000 haemophilic patients have received blood products from that plasma.
	New variant CJD is a major concern for the future, as there is no blood test for the condition and the incubation period remains unknown. The infectious particles are known as "prions". Fortunately, the risk is still considered low and the risk for haemophiliacs is not considered to be more than 1 per cent above that of other citizens.
	An interesting incident arose when one of those haemophilic patients needed a gastroscopy and biopsy of his stomach a month ago. It was performed routinely by the gastroenterologist, who was then told that the brand-new video endoscope, worth about £35,000, must go immediately into indefinite quarantine. That has compromised the hospital's routine endoscopy service to the disadvantage of many thousands who would have been treated during the planned lifetime of the endoscope. The new rule was implemented without warning or consultation with the gastroenterologists. Was it an over-reaction? The use of recombinant clotting factors for all haemophiliacs would eliminate the risks of transmissible infectious diseases. However, recombinant is still not available for English patients aged over 40.
	To prevent transmission of vCJD, some measures have been tried and found to be unsatisfactory, such as the use of disposable instruments for tonsillectomies, now discontinued. It is important to keep a sense of proportion when balancing the loss of the endoscopy service against the possible risk. It is not an easy decision.
	Hospital-acquired infections other than MRSA are also widespread, but the remedy is easier to find. Some years ago my husband contracted salmonella and was admitted to an isolation hospital. As no one knew how to cure the infection, he was treated by "shotgun pharmacy": 35 tablets a day. He was the only patient admitted with salmonella; all the others had picked up the infection in other hospitals, where they were being treated for some entirely different condition. The removal of Crown immunity from hospital kitchens has improved standards of hygiene, but food safety remains highly relevant. There are still too many cases of patients developing malnutrition in hospital, making them more vulnerable to any opportune infection.
	Hospital standards of cleaning are a matter of great importance in the control of MRSA. It is not just that contract cleaners are used in many hospitals; it is the degree of difficulty that cleaners, whatever pride they take in doing a good job, have in gaining access to the areas to be cleaned. In many hospitals, wards designed as four-bed wards have had an extra bed added. That means that the beds are so much closer together that there is not the necessary physical space for cleaning to be carried out thoroughly. Combine that with the occupancy level—in many cases, it is more than 100 per cent, as hospitals under pressure operate a "hot bed" policy, sometimes using the same bed twice in a day—and you have a recipe for rampant cross-infection.
	The National Audit Office says that the best estimate for the cost of hospital-acquired infection or my "hospitalism" is around £l billion a year. Have we returned to the pre-Lister situation? Is it for us to convince all hospital staff of the need to clean their hands between patients by washing or the use of special wipes?
	Basic hygiene is of the utmost importance. The human skin is nature's barrier to protect us; when it is pierced by surgery, by accident or by equipment, we are vulnerable. That is why it is much more important for those who are injured or are recovering from surgery to avoid contact with infectious organisms. Sterilising equipment and ensuring that cross-infection is avoided in the use of in-dwelling urinary catheters and central venous catheters is essential in minimising the risk to patients.
	Recognition of the need for basic hygiene in hospital for patients, staff and visitors remains essential and must be put into practice. Combining those old traditional ways with any new ways—such as the new way suggested today, which, I hope, will prove effective—must help to reduce the prevalence of germs and the risk of infection in the hospital. We will need more detail about the announcement made today, but we must all hope that the new spray control method will play a major part in controlling infection. I beg to move for Papers.

Lord Hunt of Kings Heath: My Lords, first, I applaud the noble Baroness, Lady Gardner of Parkes, for her initiative in securing the debate today. She has first-hand experience of the NHS as a practitioner and a trust chair. I am sure that we are all indebted to her for the way in which she has presented many of the key issues that we need to debate this afternoon.
	I also ought to declare an interest. I have several interests in the health service. They are in the register of interests, but I mention in particular my chairmanship of the National Patient Safety Agency.
	The noble Baroness took us on a tour of some of the issues and problems that we face. She mentioned cleanliness, hand washing, instrument sterilisation, antibiotic resistance, blood product issues and food safety. She also suggested, by implication, that the situation on MRSA in Russia might be rather better than the situation in the UK.
	We cannot be in any doubt that MRSA is a major problem that we must tackle, but the fact is that MRSA is a problem that many healthcare systems throughout the world are having to face up to. Although we can look abroad for some of the solutions that we need to develop in this country, we should not think that it is purely an NHS problem, to be solved by the NHS alone.
	There are many issues, and we will hear today from expert speakers about the many causes of the MRSA problem. The noble Baroness focused on cleanliness issues, and I shall discuss some issues relating to cleanliness. However, I do not accept that it is simply a matter of cleanliness; there are several issues that must be tackled.
	Looking back over the past 10 or 20 years, I think that the compulsory competitive tendering of cleaning services was a mistake. There is no doubt that the product of that process was to put all the concentration on cost, at the expense of quality. I have no doubt that, over 20 years, we saw a steady reduction in the quality of cleanliness services.
	We must also face up to the loss of authority by nurses, particularly in the ward. It has been disastrous. Coupled with the development of functional management, so that cleanliness became the responsibility of a domestic services manager and food the responsibility of a catering manager, we can see the problem that was inherited. Nurses and sisters felt that they had no authority to ensure that their wards were clean or that the food was of a decent standard.
	I also fear that the change in the curriculum for nurse training—driven, I am afraid, by the leaders of the nursing profession 10 or 15 years ago—which gave more emphasis to academic issues, as opposed to practical nursing skills, has led to a situation in which, in many places, nurses did not even think that they were responsible for having clean wards or ensuring that patients ate the food that was placed in front of them. Such issues cannot be divorced from the MRSA situation, and we must tackle them.
	There has also been a lack of recognition of some of the systematic problems of poor cleanliness. It is desirable that clinicians should wash their hands after having been in contact with a patient. On the traditional NHS wards—the Nightingale wards—there will be perhaps one hand basin in place at the end of the ward. It has been worked out that it would take up about half of an hour of work, if members of staff were to walk from one patient to the hand basin, back to another patient and so on. In such circumstances, lay people, however puzzling we might think it that doctors and nurses do not automatically wash their hands after being in touch with each patient, must also consider the practicalities of the situation. In thinking of solutions for the future, we must ensure that it is made as easy as possible for those staff to wash their hands.
	I am encouraged by the progress that has been made in the past few years. The strategies outlined by the department in Winning Ways in 2003 and the policy statement Towards cleaner hospitals and lower rates of infection in 2004 are to be commended. They set out a strategy that ought to be followed by the NHS. I also think that the noble Baroness, Lady Gardner of Parkes, underestimated the progress that has been made in individual trusts towards better cleaning and better food. The work of NHS Estates and of the PEAT teams that have gone in to inspect the cleanliness of hospitals has had a positive effect. The appointment of housekeepers on individual wards to relieve sisters of some of the day-to-day administration has also ensured a better focus on cleanliness. We should not ignore the success of the so-called modern matrons in giving back authority to nurses to sort out problems of cleanliness as they arise, rather than having nurses feel that they have no authority and that there is little that they can do about a poor situation.
	The noble Baroness was right to mention food. Again, enormous progress has been made. The work of NHS Estates and the Better Hospital Food programme has undoubtedly led to the provision of better, more nutritious and safer food to many patients. Of course, there is much more to do, but we should not ignore the progress that has been made.
	My agency, the National Patient Safety Agency, has been involved in the past few months in the cleanyourhands campaign. It is a focused campaign, and we have had a lot of support from trusts. It is about encouraging staff to wash their hands and about making it easy for them to do so. If alcohol hand-held gel is available by every bed, it will be much easier for staff to do the right thing. One's whole approach is to make it as easy as possible for staff to do the right thing.
	There are other areas. I welcome the appointment of Chris Beasley as the new Chief Nursing Officer. She is just the sort of person who we need to sort such problems out. I welcome the responsibility that she has been given for cleanliness. Getting leadership at the top to sort out the problem is very important.
	I hope that my noble friend will encourage the Chief Nursing Officer to look at the curriculum for nurse training. One of the problems that we face is that all the academics currently involved in nurse training are very much committed to the kind of curriculum that we have had for the past 10 years. Yet patients and experienced nurses say that they are very concerned that nurses being trained do not have the necessary practical skills for dealing with those kinds of problems.
	Much as I admire the deans and academics in charge of nurse training and the curriculum, left to them, nothing will change. I hope that my noble friend will give a remit to the Chief Nursing Officer to lay down the law to those people and say, "This has got to change. We have got to produce nurses in the future who really understand the basic skills of caring, which are so essential in the nursing function".
	In conclusion, there is one other aspect to which we must come back; that is, the use of more single-bed units. Of course, there is an expense involved, but MRSA is very expensive. It is expensive in terms of personal consequences for patients who are affected. But it also costs the health service a huge amount of resources in treating those patients who have to stay in hospital for much longer.
	It would be cost-effective in the long term for us to look again at how we can get many more single-bed units in the health service. Overall, we all recognise that that is a problem, but I am encouraged by the action taken by the Government. I very much will encourage them to do more in the future.

Baroness Murphy: My Lords, I speak unashamedly today from my position as an NHS chairman of a strategic health authority where we are tackling the problem of hospital-acquired infection vigorously. Before I comment further I too should like to thank the noble Baroness, Lady Gardner of Parkes, for raising this important issue and for bringing it on to the agenda. Undoubtedly, debates like this will focus health authorities like mine on tackling the issues further.
	We need no reminder today—World AIDS Day—of the devastating effect of infection on the populations of the world. To go back to the pre-Listerian era would be devastating. I have seen a quiet transformation of the general cleanliness of the hospitals in my patch—east and north-east London. We have seen a behaviour change that is beginning to have an impact.
	However, the current state of affairs in the NHS is unacceptable, and I am not here to defend it. As we all know, many western European countries do better than us. I regret that there is ample evidence that effective countermeasures are not being implemented effectively or rigorously enough across all NHS hospitals.
	Assumptions about what is necessary to move from where we are now have often been simplistic. Hand-washing is vital in the control of infection, but it is sometimes widely believed that the failure of staff to wash between seeing patients or on moving from ward to ward is due to laziness, carelessness or wilful ignorance.
	I echo strongly what the noble Lord, Lord Hunt of Kings Heath, said about the avoidance of blame. One cannot exhort people to behave responsibly or punish them when they do not do the action required. Research and experience elsewhere simply points away from the efficacy of such an approach. A large number of barriers to proper hand hygiene have been identified. Some are the result of lack of training and skills, but others are due to inadequate facilities, lack of time in a crisis, overcrowding and the poor provision of hand-hygiene agents, such as alcohol gel bottles, being conveniently placed.
	Last week, I visited the stroke unit of a hospital in my patch where frail patients are most at risk of succumbing to opportunistic infection. I noticed that the gel bottle at the entrance to the ward was on the opposite wall to that which would be most convenient when going in. I mentioned that to the ward sister. She said, "Yes, it is terrible, isn't it? I have asked them to come back and change it". We need such things to be in places where people can use them.
	However, we should remember that the bugs are getting cleverer. There are three major strains of multi-resistant bacteria emerging—MRSA is just one. Vancomycin-resistant enterococci and penicillin-resistant strep pneumoniae are also making headlines now. But escalating antibiotic resistance is likely to produce many more in the future. Our task will probably get more challenging, no matter how effectively we tackle the current difficulties.
	The good news is that we know what is effective. We know that the position has been reversed in much of the Netherlands and Scandinavia. Some parts of the NHS are making very good progress too—in particular, the Oxford Radcliffe Hospitals NHS Trust, which has a number of really effective schemes in progress. In my patch, Homerton Hospital in Hackney does consistently well and compares well internationally. Moorfields Eye Hospital, although it has less of a risk because it is a single-specialty hospital, has the distinction of having zero MRSA bacteraemic infections since monitoring began in 2001. I hope that that is not a hostage to fortune for Moorfields Eye Hospital.
	In my view, there are two very helpful Department of Health initiatives. The first was the establishment of compulsory monitoring of hospital-acquired bloodstream infection rates hospital by hospital. That means that every quarter trusts and health authorities can benchmark performance against similar institutions across the country and focus their efforts specifically on internal areas giving cause for concern.
	That feedback and the ammunition that it gives to managers and nurses charged with reversing the trend is very helpful. This Government are the first to do that. The target set for reducing by half the infection rates in acute hospitals by 2008 is challenging but, in my view, it is achievable if our current plans are allowed to bear fruit.
	The second good thing is the appointment of the Chief Nursing Officer, Chris Beasley, who the noble Lord, Lord Hunt, has already mentioned. She has been charged with leading on this matter. The noble Lord approves of her appointment. For those who know her, she is one of those rare characters who has all the admired qualities of the old-fashioned matron and, just as importantly, none of the bad. Her "street cred" in the NHS is very high indeed. Her leadership of half a million nurses in the NHS—that figure reminds us of the size of the task of turning round the NHS "Ark Royal"—is a significant asset.
	So what is happening in practice that will make a difference? The first important step is to eradicate as far as possible new incidents of infection. In our strategic health authority—I believe others are following the same track—we have a special action team that is led by one of our more experienced hospital chief executives and our chief nurse, which has now audited in detail the worst sites and has instituted targeted training programmes.
	New incidents have already dropped in the specific areas looked at. I am proud to say that currently in our health authority we compare quite well with the rest of London. All induction training courses will now include a session on basic hygiene. But we need to involve visitors too so that they understand why hand hygiene is important. We also need to educate the local public, councillors and MPs, for example, about the true situation; for example, why we should not panic, what is doable and what is not. Some of the myths need to be exploded. I am delighted to say that we have made some progress in, for example, the Barking, Havering and Redbridge area. We meet regularly with MPs in order to let them know what is happening.
	The action plan for cleaner hospitals covers the basics, but will work only if all hospitals have the kind of inspirational nursing leadership that shows by example, an identified lead person responsible for monitoring those targets and, as has already been said, a ward management system that includes permanent cleaning staff as key members of the team working under the ward manager's direction. It makes no difference whether cleaners are contracted out or in, it is who directs their day-to-day work that counts.
	So why, if we know how to do it—frankly, we have always known how to do it—has it not been done before? The advent of antibiotics in the 1940s, 1950s and 1960s before these new strains appeared undoubtedly lulled us into a false sense of security.
	Secondly, the effective management of wards was demolished by the ill-thought-out centralisation of domestic services. This had nothing to do with contracting out, which merely perpetuated what was already bad. The problem of parallel lines of management affected other professional staffs too, which militated against good multi-disciplinary work and effective unit management.
	Can anyone here remember the dreaded "cogwheel" system? It was a ghastly recipe for managerial stagnation and we are still in the throes of reversing that disaster.
	However, during the 1980s and early 1990s we saw the decline of the National Health Service system. I can remember personally the cutting of 25 per cent of the beds in London in 1984. That took place over a two-year period. Occupancy rates rocketed and have continued to do so. Patients were admitted to the wrong units, were moved about daily, which led to junior doctors running around each morning trying to find their patients, no doubt carrying infection with them. Infection thrives in overcrowded, high-turnover hospitals.
	Lastly, staffing levels among nursing and domestic staff in many hospitals were often lamentable during the 1980s. The general decline in the NHS combined with the inability of ward managers to effect change undoubtedly added to the problems of poor recruitment and an ever-changing number of disengaged, low-morale agency and transient staff.
	A healthy, infection-free hospital depends on the quality of its professional and management leaders, and their effective use of the tools now provided for them. I hope that this House recognises the excellent work now being done to tackle the complex problems of hospital-acquired infections in the NHS, and would not simply add tabloid headlines to a topic which deserves a more serious consideration of all its complex aspects.

Lord Eden of Winton: My Lords, this debate has been opened by three noble Lords of great distinction and experience. They have brought to bear a lot of knowledge and counsel in order to inform us. I am sorry to say that I shall rather let the side down. My experience is as a layman and as a hospital patient, although for me the latter was happily a rather limited experience. None the less, it is from the patient's point of view that I want to speak briefly on this subject. The noble Baroness, Lady Murphy, has an immensely powerful track record. Having listened to what she had to say, I am inspired to moderate my own views. The same is true for what was said by the noble Lord, Lord Hunt. I recall very well what an excellent Minister he was when he served in the Department of Health. Moreover, I am sure that all noble Lords are grateful to my noble friend Lady Gardner of Parkes for introducing this subject in such a rounded and measured way.
	I am never quite so measured in my approach to subjects under debate and I feel quite strongly about this issue. I have had experience of filthy hospital conditions. I shall mention a small thing. I was about to put on one of those appliances that enable patients to listen to the radio without disturbing anyone else. It was coagulated with dirt and obviously had never been looked at, which is quite unnecessary. As I say, that is a small thing, but it would serve as a means by which infection could so easily be transmitted.
	I also noticed the cleaner made only a very superficial act of cleaning with a mop. Gone are the days, apparently, when someone got down on their hands and knees with a scrubbing brush to attend to the dirt on the floor, cleaning and disinfecting it properly. I know that the noble Lord, Lord Hunt, pointed out that it is difficult for doctors to wash their hands every time they move from one patient to another, but surely it is not beyond the realm of human genius to devise a means by which they may do so. A bucket of disinfectant placed at the end of each bed or a device whereby new surgical gloves can be picked up before moving on to the next patient should be possible. I do not know. It is not my job to be a hospital manager, nor is it the Minister's job. It is the hospital manager's job to manage the hospital.
	Over the past four or five years we have had a whole series of reports, studies and recommendations, but in the mean time we have not had enough follow-up action. In January 2001, Department of Health guidelines were published on the prevention and control of hospital-acquired infection. They set out a whole series of standard principles covering hospital environment hygiene. In January 2002 we had Getting Ahead of the Curve, in which the Chief Medical Officer made a number of recommendations to tackle hospital-acquired infection. The most important of those recommendations was that:
	"There should be leadership and commitment from the top of all local NHS organisations to ensure that infection control is a core component of clinical governance".
	So it should be, yet in December 2003 we had yet another publication entitled Winning Ways, explaining the Department of Health's drive to tackle hospital-acquired infection. It proclaimed that every NHS trust was to get a director of infection control and infection control teams. A healthcare commissioner was to be asked to make infection control a key priority when assessing hospital performance.
	All that is good, but what has happened? NHS bugs go marching on, apparently becoming more and more virulent and resistant to the treatments that have been devised to tackle them; so much so that, as my noble friend Lady Gardner pointed out, the National Audit Office produced a report in July of this year. It reported that progress on reducing MRSA since 2000 had been "patchy". The NAO went on to comment:
	"If all the recommended measures had been brought in across the NHS in 2000, infections and deaths would have been cut by 15 per cent a year, saving some 750 lives".
	The NAO report also found that hospital infection teams lacked both the resources and the clout to have an impact. It found high levels of bed occupancy and waiting-list patients accommodated next to those with trauma. There was a lack of isolation facilities and patients were moved about too frequently. I am sure all noble Lords have seen that. Patients are moved along corridors with no attempt to mask them against the possible inhalation of infectious bacteria. I have been taken on a trolley to and from an operating theatre. We entered a lift which visitors to the hospital were also using. It is mind-blowing that that sort of thing still goes on, given all the effort that is supposed to have been put into treating hospital-acquired infection year after year. Why is that?
	The report went on to deplore the fact that there is over-prescription of antibiotics, and noted non-compliance with good infection control practices. Not surprisingly, the Auditor-General, Sir John Bourn, commented:
	"I am concerned that, four years on from my original report, the NHS still does not have a proper grasp of the extent and cost of hospital-acquired infection in trusts".
	Curiously enough, that report was published on virtually the same day last July as that on which the department produced its own publication, Towards Cleaner Hospitals and Lower Rates of Infection. It set out a new charter for hospital matrons. Since then, I believe that I am right in saying that over 3,000 matrons have been appointed with the power to withhold payment for poor cleaning services either from the in-house provider or from the external contractor. They have those powers, but have they been acted on? Has anything been done to use those powers? Has the Minister any evidence that he can bring to the attention of the House of a contractor being dismissed and replaced because of a failure to observe proper standards of cleanliness in the hospital? I know the difficulty of employing contract services, so I have sympathy with the comment made by the noble Lord, Lord Hunt, in that regard. However, they are there and they do not always perform as they should.
	Management makes the contract with the contract manager and it appears that the management and not the matron has authority over the cleaners. Management is the key. We do not need any more reports, investigations or elaborate research. We need action and we need action by management that has the responsibility and authority to manage. That means management must have both sanctions and the power to give rewards. One cannot have management without the ability effectively to reward those who do well and punish those who do badly. That is what management is about.
	I am afraid that there is too much of the egalitarian ethic in hospitals, which makes it very difficult for managers to exercise proper management. If the matrons are to be held accountable, then matrons should have the powers to discharge their responsibilities. Immediately let us have hospitals being required to publish their inspection control procedures stating who is in charge of delivering a clean and safe environment on a ward-by-ward basis in each hospital.

Baroness Pitkeathley: My Lords, I too thank the noble Baroness, Lady Gardner, for giving us the opportunity to debate this important issue. Like the noble Lord, Lord Eden, I also speak from my experience as a patient—in fact as a sufferer and, as you see, a recoverer from MRSA. I have shared this experience with your Lordships before, but I make no apology for repeating myself because it is important that we understand the context of hospital-acquired infections as well as appreciate the efforts which are made to deal with them, often in the most difficult of circumstances.
	I also think that it is quite easy to be panicked about this issue. I am not in any way minimising the deaths that take place from these infections or the seriousness of the problem. However, we should remember that many hospital patients suffer from hospital-based infections—some, like me, very seriously—but, like me, recover and have absolutely no long-lasting effects.
	I join with others in being very concerned not to apportion blame because I am pretty sure that I can pinpoint the moment that I acquired MRSA, and I feel gratitude not blame. I was suffering from a complete body sepsis after surgery for cancer and a bad reaction to chemotherapy drugs. Admitted to the Middlesex Hospital on Christmas Eve, the doctors despaired of my life and told my family to make arrangements for my disposal. Then a wonderful and courageous surgeon told my family that he was prepared to operate. I say courageous because many surgeons would be too aware of their mortality rate batting average even to suggest such a course of action in an apparently hopeless case, even if it had not been, by now, Christmas Day.
	Although he could offer only a less than 1 per cent chance of survival, without the surgery the outcome was certain death, so my family, knowing that I would always take the high-risk option, agreed. But here was another problem, since I was so ill that even moving me to the operating theatre would surely kill me. So they decided to operate in the room which I was occupying in intensive care. There was no time to ensure the sterility of the room of course—they did the best they could in the short time available—but I can be fairly sure that that was the source of my infection. That operation was not the end of the story; much more surgery and many months of devoted care followed, but I think your Lordships will not be entirely surprised to know that had I been conscious enough to make the decision, the risk of getting MRSA would have been the least of my problems and one that I would have been prepared to take.
	I tell this story to illustrate the complex nature of the decisions that surgeons and nurses have to take—often with very little time to spare, often with lives at stake, often involving great risk, and often weighing a least-worst option against another bad option. I too join the calls for more vigilance against the spread of these infections, but we must always remember the practical circumstances of those who are responsible for patient care. I cannot fault the precautions which the staff in intensive care took to try to prevent the spread of infections. Such few visitors as were allowed were always told about washing their hands, wearing aprons and applying disinfectant lotions. However, as we have heard, ward rounds involve doctors and other staff moving from bed to bed, sudden emergencies arise and deliveries of supplies are essential.
	When one moves from intensive care to a ward, those precautions are even more problematic. Visitors have free access to most wards at most times of the day. Patients go endlessly to X-ray, to physio, to ultrasound, and all offer opportunities for infection to spread. But these visits are essential. I was nursed in isolation for much of the time, but there were only two side rooms on the ward, so what happens when more than two patients require barrier nursing, as the noble Baroness asked?
	When one is immediately post-operative, the nurses need to keep one under close surveillance. The side ward with its closed door, where MRSA patients are often nursed, is not then the safest place, in spite of the risk of infection. If a crash call comes when a doctor is attending one patient and knows a colleague is alone at the other end of the ward, washing one's hands and changing one's apron may not be the first thing on one's mind, even though we know that they ought to be.
	If there is only one night sister or house doctor on call for a large group of wards at three in the morning and a new line or ventilator is urgently needed, it is perhaps understandable that hygiene sometimes takes second place.
	If a patient is unable to eat for months on end, as I was, the only means of keeping them alive is via a Hickman line putting food into the blood stream. By their very nature, such lines become infected within a few weeks. One then has to balance the risks of sending the patient back into the theatre for more surgery—because a new line has to be put in under general anaesthetic—against the risk of the spread of infection. I offer these examples of difficult decision-making not as excuses but to ensure that we never lose sight of the difficulties faced by the staff to whom I and many others owe their lives.
	I am sorry to have to relate that I have had more experience in recent weeks of how we are doing with tackling this problem through the prolonged illness of a member of my family. I have been very struck through observing two hospitals now and two lots of critical care facilities how much progress has been made with this issue in three years. It is very clear that everyone who works in the hospital system is infinitely more aware of the problems we are facing with infection than they were three years ago. There are many more hand-washing facilities and there are notices on wards in what is known as the "rellies" or relatives' room on every ward. The provision of hand-washing and chemical wipes at the entrance to every ward and cartoons on the walls are all serving to bring the dangers more firmly to our attention than hitherto.
	The emphasis that the Government have placed on patient and public involvement is clearly bearing fruit in making both patients and the public willing to take personal responsibility. It is commonplace now in hospitals to see patients and relatives reminding other visitors of the necessity to take hygiene precautions—even people with whom they have no connection at all. I have witnessed that with my own eyes. People say, "Hey! You haven't used the alcohol wipes or washed your hands since you came into this ward". That is the best illustration that one can have of the shift in public attitudes that has taken place since campaigns about the spread of infection have gathered pace.
	However, the best way of avoiding hospital-based infections is not to go into hospital at all, or, if one does, to go in for as short a time as possible. In that regard, the Government's policies are to be very much validated. There is increased co-operation between health and social services, and a shortening of the time that it now takes to arrange care in the community, as a result of the Community Care (Delayed Discharges etc.) Act 2003. That effect is noticed particularly by older people who have orthopaedic surgery, because in their postoperative period they are especially prone to infection and it is notoriously difficult to overcome. Moreover, most people want to return home as soon as possible. We are now able to give GPs access to minimum data on patients to allow them to assess a patient seen as an emergency out of hours in his or her own home. Instead of admitting patients to the A&E department, we can provide monitoring at home, thus avoiding the risks of hospitalisation.
	Another very important element in the fight against hospital-based infections, to which the Government are committed, is the development of the small diagnostic and treatment centres. They are already established in some parts of the country and many noble Lords will have seen them working very well in the United States. They specialise in cold surgery and patients are in and out in a day. Patients, while sometimes reluctant at first, are almost universally supportive of those systems and of the individual attention that they can bring.
	We must continue to improve hygiene in hospitals and to fund appropriate research. I hope that the Minister will be able to say more about the research that is planned on this issue and about plans for further public awareness campaigns. But we must keep people out of hospital as much as possible by looking at other forms of care, which will not only preserve them from infection but also offer them treatment and care that fits their lifestyle, instead of expecting them to fit in with hospitals' routines and cultures.
	I hope that we can all approach the undoubtedly challenging task of tackling hospital-based infections in a way that offers help, not blame, to the NHS and its skilled and devoted staff.

Lord Soulsby of Swaffham Prior: My Lords, this House must be very grateful to my noble friend Lady Gardner of Parkes for this debate on hospital-acquired infections at a time when hospital wards will be increasingly busy with the onset of winter, with more elderly people in those wards, more intensive and invasive procedures being performed for diagnostic tests, and, above all, a population of bacteria that are increasingly resistant to antibiotics, many of which are proving to be quite useless in the treatment of infection.
	The organism of primary concern has been mentioned—namely, methicillin resistant staphylococcus aureus, or MRSA. This still hits the headlines in the news media. As other noble Lords have said, it is a sobering fact that European Antimicrobial Resistance Surveillance System in 2002 identified the United Kingdom as having the highest level of resistant MRSA bloodstream infections, as a proportion of all staphylococcus aureus bloodstream infections, in Europe—that is, 43.9 per cent. Nearly 50 per cent of all bloodstream aureus infections were resistant. That is compared with the system in Sweden, where the figure is 0.7 per cent, and in Denmark where it is 0.9 per cent.
	I mention Sweden and Denmark particularly as those two countries have taken very strong measures to control antibiotic resistance in general, including the abolition of the use of antibiotics as growth promoters in livestock. It may to noble Lords seem a very far cry from resistance in hospital wards to staphylococcus aureus, or MRSA, to the use of antibiotics as growth promoters in animal feed. But there most likely is a connection, and the Swedes and Danes will recognise that because there is an increasing and massive environmental contamination of the genes of resistant organisms generally spread throughout the environment, derived from massive use of antibiotics in medical, veterinary and horticultural circumstances.
	I tend to call it genetic zoonosis, whereby the genes of the resistant organisms are very widespread. We should remember that when we use antibiotics for the treatment of pathogens in whatever animal, whether human or otherwise, there is a far greater population of bacteria—the commensals—that are also exposed. They become resistant and transmit resistance to other commensals and other pathogens. That is an increasing problem, which I am glad to say Defra is now taking up to study in greater detail.
	The statistics of hospital-acquired infections are of course horrendous. They have been mentioned by other noble Lords. At least 100,000 hospital-acquired infections occur per year, and 5,000 deaths are directly attributed to them. Another 15,000 deaths are contributed to substantially by such infections. Those statistics, as stated by the Chief Medical Officer, cannot convey the human toll that goes along with MRSA. There is an abundance of reports of previously healthy people who have become seriously ill or died as a result of hospital-acquired infection. We have just heard the noble Baroness, Lady Pitkeathley, give a graphic account of how near she was to death.
	At times, people enter hospital for minor procedures and/or minor surgery, and then suffer from infection. A friend of mine recently told me that she went to a major hospital in an area not too far from here, having broken a bone in her wrist. Following surgery, her whole wrist became infected with MRSA. It was eventually controlled with vancomycin treatment, but she was warned that she might have to have her hand amputated if the treatment was not successful.
	So what do we have to do about this? There is no doubt that the magic bullets of antibiotics have lost their magic, and many people feel that the bugs are winning. The human toll is growing and the economic burden to the health service must be great. I wonder whether the Minister has any information on that matter. The report from the National Audit Office in 2000 estimated an amount of £1 billion a year. I wonder what that figure is now. Will the Minister give us some idea?
	What progress has there been in the reduction of hospital-acquired infections? Mention has been made of the CMO's report of 2003, Winning Ways, which showed that the degree of improvement has been small. In the debate on 8 December 2003, when I had the privilege of introducing the Science and Technology Committee report on fighting infections, it was noted that the new Health Protection Agency would appoint an inspector of microbiology and in addition £12 million would be provided to tackle hospital-acquired infection. What progress has been made by the inspector? Has the funding been adequate, and is it still available for this important area?
	While major attention is, rightly, directed towards MRSA, there are other organisms. One of these is the problem of antifungal agents. They have received a low profile in debate, but the yeast candida albicans is an opportunistic fungal pathogen causing severe and potentially fatal disease in immuno-suppressed patients, especially those with AIDS. Fungi differ from bacteria in that the potential for the rapid emergence of resistance is much less with candida than with bacteria. Nevertheless, the fungal infections in AIDS patients are a serious problem, leading to the appalling mouth infections that one occasionally sees.
	As a postscript to the currently sad tale of hospital-acquired infections and MRSA, the pipeline for the development of new antibiotics is drying up. Major pharmaceutical companies are increasingly less interested in investing in the development of antibiotics. It is a prolonged and costly business to do so, and the product that is so developed may end up with a very short clinical life due to antibiotic resistance. Can the Minister give us any idea of what encouragement the Government are giving to pharmaceutical companies, large and small, to undertake antimicrobial discovery for the future?
	The Infectious Diseases Society of America, which details problems in the United States which are very similar to those we are talking about today, has put out the following cryptic message:
	"As antibiotic discovery stagnates, a public health crisis brews".
	I believe that we in the United Kingdom are very much in the same position: hospital-acquired infection is a public health crisis and antibiotic discovery is stagnating. Perhaps I may ask the Minister what action he and his department think needs to be taken to alter this situation.

Lord Turnberg: My Lords, I too am very pleased to commend the noble Baroness, Lady Gardner of Parkes, on introducing this very important topic. I am also aware that much of what I shall say has been said very eloquently by others. It was hard not to be moved by the speeches of the noble Lord, Lord Eden, and the noble Baroness, Lady Pitkeathley, who so eloquently described what happened to them. I have to express my interest as an ex-physician and as ex-chairman of the Public Health Laboratory Service, now the Health Protection Agency.
	It is an opportune time to be debating this topic again because, as we have heard, the Government are trying very hard to get at the causes of hospital- acquired infections. I say "debating this topic again" because, of course, it is not the first time we have discussed it. Indeed, when I was thinking about what I might say, I realised that the reason it was so familiar was that I gave my own maiden speech in a debate on the subject four and a half years ago. Some might say that I am in a rut. But the issue was not new even then, and if the problem was easily soluble we would have done it by now. Certainly quite a lot of effort has gone into it. But just as the causes and contributing factors to these infections are multiple, so their prevention and treatment will have to be multifactorial too.
	My overall request to my noble friend the Minister, as he attacks the problem with his customary vigour, is that the Government do not focus too hard on only one or two potential remedies, but look more broadly at a range of simultaneous actions that will be necessary, including the need for more research and information, which is surprisingly lacking in a number of areas.
	There are some factors that contribute to the high incidence of hospital-acquired infection which we can do little about. For example, the patients who are most at risk of getting a bacteraemia—that is, the bacteria entering the bloodstream and potentially leading to septicaemia—are likely to be those who are the most sick and the most elderly. Of course it is not only those, but they are the vast majority. It is just those patients who are vulnerable and whose immunity is at its lowest ebb who die of hospital-acquired infections. But it is just those sorts of patients who require the care that only hospitals can provide, as the noble Baroness, Lady Pitkeathley, described. Most younger, fitter patients are treated at home. So we cannot do too much about that.
	As other noble Lords have mentioned, there is also not much we can do, in the short term at least, about the horrendously high bed-occupancy rates: over 90 per cent in most hospitals and over 100 per cent in some. I could explain how it is possible to occupy beds over 100 per cent, if anyone so wished. However, these rates are the highest in Europe, where the average is nearer 70 per cent, and that is despite the enormous investment that the Government are making in new hospitals. The investment is making a difference, but we still have some way to go before we can afford what they seem to be able to do in Holland; for example, where they can close wards and even whole hospitals without apparent pain. We can ill afford to do that when waiting list initiatives would be frustrated and managers' jobs are on the line.
	Although I am delighted to commend the Government on increasing numbers of doctors and nurses in the health service—a very welcome step in the right direction—it is still the case in many hospitals that staff are run off their feet, and washing one's hands while running about is not an easy act. If, for example, you have a doctor doing a ward round of 30 patients, which is an average ward round, and she stops to wash her hands after every patient, which takes on average an estimated two minutes, that would add an extra hour to the ward round, to say nothing of the sore hands.
	I know that more staff are in the pipeline, but, meanwhile, high patient throughput and rushed staff under pressure are not conducive to best practice. These background factors form the context in which we have to try to introduce change, and they will in themselves limit what can be achieved by the methods and the measures we can and should introduce.
	So what can we do? First, we have to recognise that the organisms that cause the life-threatening infections may be very widespread on carriers who themselves are not affected by them. Such is the case for staphylococci, which many of us carry in our noses and which of course may be carried by staff and visitors as well as patients. I speak here not of MRSA—not of methicillin resistant staphylococcus—but of sensitive staphs, which means that they are potentially treatable with methicillin. But we should not make the mistake of believing that that is a minor infection. It will kill vulnerable patients just as readily as MRSA if it gets into their bloodstreams and they do not get their methicillin quickly enough. So it is potentially dangerous, but we cannot easily prevent it getting into hospital.
	What about MRSA? This seems to be much less widely distributed in the population, but even here we do not know much about its distribution. We can do with more research on that. It is found mainly in hospital patients, most of those affected being carriers, for example, on their wound infections and the like, and in nursing homes. It is most often spread by patients coming from other hospitals and by staff. Incidentally, the high use of agency staff who move around quite a bit from hospital to hospital is a potential risk. I would certainly urge my noble friend to look at whether agency staff present a real risk or simply a theoretical one.
	It follows from all of that that the major teaching hospitals and specialised hospitals—which receive most patients from other hospitals, who are often the most sick—are most at risk.
	One way of tackling the problem of inter-hospital transmission would be to use a simple, rapid diagnostic test on nasal swabs of all patients on transfer to a new hospital, a test that would have to be available and tell one within a few minutes whether a patient was clear of MRSA. That would be enormously beneficial, but unfortunately such a test is not yet available. There is research into this. Perhaps I may urge my noble friend to invest in the continuing research needed to bring such a test into practice.
	Perhaps I may also say a few words about MRSA, in contrast to the comments of the noble Lord, Lord Soulsby. I have had conversations with colleagues at the Health Protection Agency about the problem of development of antibiotics. I understand that although MRSA is certainly resistant to methicillin, they believe that it is not untreatable. The picture is somewhat less bleak, in that there are now at least four new antibiotics in use to which MRSA is sensitive and five others are undergoing trials. I am trying not to downplay the dangers of MRSA, but simply to point out that all staphylococci are dangerous if they enter the bloodstream. They are very nasty and need urgent treatment. It is not just MRSA that needs treatment.
	I have deliberately steered clear so far of the business of cleanliness—not because it is unimportant, as the noble Lord, Lord Eden, so graphically described; it is clearly very important—but because I wished to put it into the perspective of everything else that needed attention. Clean wards are an entirely desirable basic need; they are the baseline upon which we should be working. Even more important is the thorough cleaning of beds, mattresses, lockers and all the various telephones and attachments which patients use when one patient goes out and another comes in. However, all that comes at a cost—in this case to the patient, who may have to wait another hour on a trolley in the accident and emergency department while all of that is going on, due to high bed-occupancy rates.
	Of course, cleaning hands between patients is vital. But washing at a sink is impractical, as other noble Lords have said. But now we have available alcohol gels which are probably much more effective than soap and water. It is an important advance, because hands can be cleaned much more quickly and it is good for the skin, too. I understand that ladies love the gel because it contains glycerol and makes hands feel nice and soft. This is a practice that clearly needs to be spread far and wide and is something that could be monitored, for example, by hospital pharmacists who could keep a note of the ward usage of gels. It is a matter of monitoring.
	There are yet more areas that need exploration. Greater attention to aseptic techniques in the insertion and aftercare of intravenous lines, which are a potent cause of bacteraemia, has already been mentioned. There should be a survey of the practices of those hospitals which seem to manage to avoid hospital-acquired infections, at least regarding MRSA. MRSA rates vary enormously, from around 1 per cent to some 50 to 60 per cent of all bacteraemia. It is unclear why there is such a variation. Why has the Homerton Hospital only a 1 per cent rate? That would certainly merit some research. Research into why some carriers of infection seem to be so-called super-shedders, who spread their germs much more widely than others, would be of interest.
	There is much that can and should be done. But if we are to surmount the problem we will need to attack it in a number of ways—multi-focused attacks. I hope that I can encourage my noble friend to take a holistic approach.

Viscount Bridgeman: My Lords, I am grateful to my noble friend Lady Gardner of Parkes for initiating this debate. Perhaps I may say how heart-warming it was to hear the speech made by the noble Baroness, Lady Pitkeathley, regarding her personal experience of the subject of the debate. All noble Lords rejoice in seeing her very firmly in her place.
	I shall start on a possibly provocative note, comparing the experience of hospital-acquired infection between the NHS and the private sector. Your Lordships will be aware that the great majority of consultants practising in the private sector have NHS contracts and many will move between establishments in the two sectors in the course of a day. Their experience of the incidence of HAI between the two is truly startling.
	I must declare an interest as the chairman of an independent hospital and hospice. I am certainly not here to blow the trumpet for the independent sector. I am too well aware of the interdependence between the two sectors, which is, happily, growing in their different ways. I should mention that the hospital of which I am chairman has a hospice wing which is wholly within the National Health Service.
	In the matter of organisation and accountability of staff, the private sector may well enjoy an advantage but I do not wish to discuss that here. My purpose is simply to show, in a visible way, that there is no clinical reason why hospital-acquired infections cannot be reduced to an acceptable level. So, regarding what I am now about to say, the private sector leaves the scene. There are one or two features of the National Health Service in which cost is not a consideration—they have been so well covered.
	I next wanted to raise the washing of hands between seeing patients, but I could not improve on the comments of the noble Lord, Lord Turnburg. However, the problem cannot be ignored. If hospital staff have to do the marathon to the end of nightingale ward, as the noble Lord, Lord Hunt, described, they must do it.
	The noble Lord, Lord Turnberg, also referred to my next subject, which is the much wider use of pre-admission screening, where swabs will detect many infections upon which action can be taken before they can cause cross-infection complications in hospitals. Noble Lords have referred to the matter of cleanliness in the wards. We are continually hearing stories of this in the media. And I am sure that I am not alone in finding it difficult to see why this—which amounts to a scandal—cannot be addressed. In any industry or profession where the matter of cleanliness is identified, whether in the office or on the shop floor, something is normally done about it and promptly.
	In the National Health Service the majority of cleaning work, as the noble Lord, Lord Hunt, said, is now out to contract, with the best-value criteria being dominated mainly by cost, with delivery taking second place. One hears all too frequently of ward sisters wringing their hands in frustration at the lack of cleanliness on their wards. It affronts their own professional standards, but there is nothing that they can do about it because they have no control over the cleaners. If a supervisor can be found, He, or she, is likely to say that he has very few hours to clean an impossibly large number of wards, but that that is their contract and they cannot do anything about it.
	The problem must be addressed with urgency. The tendering system must be changed so that contractors are made more accountable to the nursing management. I compare that with refuse collection by local authorities, which is also almost universally out to tender. Certainly, in my own borough, a complaint to the council is dealt with promptly and, on the whole, effectively, with apparently close communication between council and contractor. The noble Baroness, Lady Murphy, and the noble Lord, Lord Hunt, have referred to welcome initiatives by individual trusts and I hope that that will become a national trend.
	The noble Lord, Lord Hunt, referred to side rooms and single beds, as did the noble Lord, Lord Turnberg. The NHS of the 1980s has received a bad press from the noble Baroness, Lady Murphy. But it is a sad commentary on that period that there was a trend to close side wards and turn them into—wait for it—offices. I am told that there is now a welcome move to reverse that trend and to restore side rooms to their originally intended use.
	The matter of over-crowding has also been mentioned. The guideline, as I understand it, is that that there should be one bed's width between each bed. That rule frequently cannot be observed due to pressure for beds. Associated with it is the matter of segregation and more isolation rooms. Best practice is for surgical and medical cases to be kept separate, with ring-fencing of elective surgical beds, But, again, pressure of admission of patients all too frequently means that a medical case has to be slotted into a spare bed in a surgical ward, and it is in the interface between medical and surgical cases that some of the greatest risks of cross-infection occur.
	Perhaps I may briefly refer to surveillance. A large amount of data on HAI is being collected, but there appears to be little evidence that it is being analysed and the findings acted upon. The feeling among the specialists involved in this field is that it is only when the findings have been established and published that the real extent of the problem will become known, and I am told that it is likely to be of frightening magnitude. Many of the statistics which result from surveillance appear to be—dare I say?—deliberately withheld. For instance, in the year to March 2004 there were 7,647 bloodstream infections due to the MRSA bug. I am advised that of that figure, an alarmingly large proportion resulted in the death of older patients; but that figure appears to be closely guarded by the department.
	Finally, I turn to drug prescriptions. I assure your Lordships that I am not attempting to put myself forward as an expert on this matter. Indeed, I refer directly to the noble Lord, Lord Soulsby, on this. The NHS needs to develop a strategy on rational antibiotic prescribing. It is well known that in the past 40 years the drug companies have made comparatively little out of new antibiotics, a point made by my noble friend Lord Soulsby. Their money comes from lifetime-use drugs, such as those for blood pressure, arthritis, diabetes or to treat cholesterol. The result is that very little research is going into new antibiotics and such new drugs that come on to the market tend to be clinically useless after a while, as bugs develop resistance, and they have more adverse side effects for patients. Rational antibiotic prescribing involves the use of simple drugs and moving on to the use of broad-spectrum ones only when the simply ones are not effective. A more exhaustive use of this procedure could well result in a cheaper drugs bill and, significantly in the context of this debate, fewer drug-induced infections.

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for again bringing up this very important matter. In February 1996, I brought up the increasing problem of methicillin resistant staphylococcus aureus in an Unstarred Question in your Lordships' House. I saw it then as a growing disaster. We have had two Select Committees in your Lordships' House, which made many sensible and practical recommendations on infections and resistance to antibiotics. MRSA seems to be like the sea when King Canute told it to go back and it did not do so.
	Mr Reid, the Secretary of State for Health, has said that the Government are committed to a relentless campaign to control MRSA. The chief nursing officer, Christine Beasley, has been told to make MRSA her top priority. She has said that more than a million NHS staff would get infection control training. That should have happened a long time ago. It is not just nurses who should be being trained but everyone who is in touch with patients. About three years ago, I was a patient at Stoke Mandeville Hospital, having broken both legs. A young man used to come into my room and clean, but he never cleaned under the bed. So I suggested that he did and explained that germs live in dust and that dust gathers under beds if it is not removed. He said that I was the first person who had told him that. It does not matter whether cleaning staff are in-house or are employed by contract agencies. They all need clear guidelines and training on how to clean. As most of the people doing this work come from all parts of the world, it should be seen that they fully understand. The young man I was dealing with came from Puerto Rico.
	The noble Lord, Lord Hunt of Kings Health, used to be asked by some of your Lordships how the process of appointing matrons was progressing. A short time ago, I met a matron from Birmingham who was charming but I wondered whether she was the right person for the job. Perhaps, armed with the new cleaning manual, which should have gone to every NHS hospital, she may manage. Can the Minister say what response has there been to the manual? Is it being used throughout the NHS?
	A few weeks ago, I attended an open evening at the Harrogate District Hospital, which is having foundation status. It was showing different departments to the public. The microbiology department ran a clean hands campaign. One scrubbed one's hands, came back and put some gel on them, and then put them under an ultraviolet light that showed whether your hands were clean. If they passed the test, one was presented with a large foam hand with, "My hands are clean, are yours?" on it. I have such a hand with me.
	Earlier this year, my husband was in intensive care at a local hospital for three weeks. I was pleased to see that all visitors washed their hands on entry. It was not so in the other wards. The use of gel is more available now but it should be everywhere, with notices telling people why they should use it. The Secretary of State has said that MRSA bloodstream infection rates are to be halved in our hospitals by 2008. As the number of infections is now very high, this is still alarming to anyone going into hospital as they may become one of the statistics.
	Can the Minister tell the House about the wonder paint that wards off infection? I read that, while trying to find a substance to counter mould, a British paint firm accidentally invented a disinfectant that fights MRSA. Manchester-based HMG Paints came up with Byotrol, a non-toxic and odourless liquid that repels any bug that lands on it. It works particularly well against MRSA. I ask the Minister whether this paint is effective and, if so, is it being used in our NHS hospitals?
	I am absolutely convinced that the majority of the public wants really clean hospitals. For years, there have been concerns about this. Having read about the Lincoln enhancer—a British invention with a high speed cleaning head and a polisher that saves time—I wondered whether effective new devices coming on to the market are tried out by the NHS Purchasing and Supplies Agency and whether it has an approved list of products. That could save millions, if not billions, of pounds. Clean hospitals not only save lives but they also raise morale.
	Can the Minister tell the House what progress is being made in creating detergents laced with viruses that could rid hospitals of superbugs? Because new antibiotics to replace those made obsolete by superbugs take so long to develop, researchers at Strathclyde University are trying a different approach and have targeted a special type of virus, called a bacteriophage, which attacks bacteria only. Bacteriophages are the natural-born killers of the microbe world. They can infect and destroy bacteria only and cannot harm humans. The research team has used solids with special surfaces on which bacteriophages can be fixed and where they can thrive. The genetic material that creates hundreds of copies of the phage eventually bursts open and the phages spill out and infect other bacteria and, it is hoped, kill MRSA. This sounds exciting and interesting and I hope that the Government are interested in this type of research too.
	I bring the matter of hospital planning and bed space to the notice of your Lordships. Even Florence Nightingale recognised the need for adequate space between beds to lessen the risk of the spread of infection. Guidance from NHS Estates, which oversees design and planning matters, states that the space between hospital beds should be 3.6 metres—11 feet 8 inches—to reduce the spread of infection. But the new 18-storey University College Hospital, which is due to open next year at a cost of almost £422 million, has just 2.7 metres—8 feet 8 inches—between beds. The problem was spotted by an architect when he and other local residents were shown around the hospital this year. After the NHS trust refused to move the beds further apart, he instructed solicitors to take up the case. UCH said that the new building had been agreed and finalised in 2000, two years before the new NHS Estates guidance on bed spacing.
	With the rising hospital infection rates and the Government's challenge to bring down the rates, surely they must see that their guidelines are adhered to. Surely the safety of patients should be paramount. If the private finance initiative is not following the Government's guidelines throughout the country when building new hospitals, what are the Government going to do about it?
	There are many infections such as E. coli, TB, legionnaires' disease, HIV, salmonella, pseudomonas, enteritis, hepatitis, and so on, which are dangerous to vulnerable patients in hospital, but MRSA is by far the most prevalent. Hospitals are under immense pressure, and infections increase this pressure. Therefore, there must be better hygiene and discipline all round.
	Last year, yet again, I broke a leg in two places in your Lordships' House by getting it stuck in a door. As I am classed as a vulnerable patient, it was suggested that I did not have the leg operated on at St Thomas's Hospital because of the risk of MRSA. I was treated at St John and St Elizabeth, the hospital chaired by the noble Viscount, Lord Bridgeman. Because I had a single room in that hospital, I was thankful to avoid MRSA, but it is a serious matter when patients have to dodge MRSA by moving hospital.

Lord Selsdon: My Lords, we have talked of Lister, Florence Nightingale and Canute in this debate, and I suppose it would be right for me to go back even further. I shall explain to your Lordships the reasons why I speak.
	I was for many years a director of a company called Terme di Porretta, the oldest spa company in the world, whose technical team found Aquae Sulis and operated many of the Roman baths around the world. We did not cure people, we rehabilitated and treated them. We were taught that disease could be spread by water, by air, by touch, by food and, in war, by blood. Plus c"a change. As I look at the right reverend Prelate the Bishop of Portsmouth, I recall that next year is the year of Nelson and Trafalgar. People would lose their legs and their limbs because of splinters from cannonballs, not from the cannonballs themselves, and from septicaemia and amputation.
	In our spa company, the one thing we used, even in ancient days, was fire, because fire would burn everything. Later, we even used maggots; they were used extensively in the First World War and are coming back into use. That is the first reason I speak.
	The second reason is that my wife had a small operation on her leg in one of the private hospitals. We went away for Christmas and while we were away, she was ill. She was in great pain and seemed to be infected. We took her to a very elderly doctor, the only one who was available at the time, who used to fish in Scotland and enjoy quite an amount of whisky. He said, "This is rather like the war. It is a question of gangrene. We could try maggots, but I think it may be a disease special to the United Kingdom, and you should take your wife back immediately to London. Drive in the fast lane because it is smoother and will be less bumpy for her".
	My wife's own doctor's son had a car accident and went to a similar hospital to have a metal plate inserted. He now finds that MRSA is incorporated within the stainless steel in the pits thereof, and the whole thing may have to come out.
	This morning, in preparation for this debate, I went to see the Health Foundation. I was reminded, very gently, with a piece of paper, that 44,000 people are killed in hospitals every year, due to the wrong prescription of medication, the wrong treatment or through hospital-borne diseases. That is 110 people per day, more than are killed by road accidents or accidents at work. So this is a broad problem, before we come to the individual technicalities of the disease.
	In my international world, I have been exposed to legionnaires' disease, SARS, blackwater fever, polio and meningitis, but I was never frightened until I went to the AIDS ward in Barts, where they have wonderful treatment. Somehow, going on that dark night, with rain and not much light, you thought you had walked back into the past.
	When I learnt about MRSA, I began to be frightened even to go into hospitals. I was brought up at a time when there was no central heating, you had a cold bath in the morning and were brought up to believe that coughs and sneezes spread diseases and, as the 1942 campaign said, you should trap the germs in your handkerchief. This is a long time ago, but I have been fortunate enough not to have had to go to hospital; I do not seem to suffer much. But when I see the fear of people who need a minor operation that they may contract something serious in hospital, that is worrying. I worry that even this debate may create too much fear.
	We have various initiatives. The noble Lord, Lord Hunt, spoke about the Government spending £4 million on patient protection, but, fundamentally, certain changes have to be made. I shall now try to make a speech as though I were a Minister, which I never have been and never will be. But if I were, I would say that we have more hospital beds per thousand of the population than the United States, Canada, Australia and much of Scandinavia. We have 3.9—less than in Scotland, where they have 4.1. Even more importantly, we have more people employed per acute bed than any other OECD nation. We have between five and six, whereas France and Germany have between one and two.
	I do not make this point to say that there is anything wrong, because four members of my family have worked in the National Health Service—one is working in it now. I have learnt an awful lot from them over time, and I have a great respect for the NHS. However, if any of us were ever ill, we were always advised to go to a vet because they had wider experience of diseases that could be carried by mammals, and a longer period of training, particularly in Scotland.
	What is the Government's plan? What plan is there? We see the biggest level of proposed investment in the health service of any nation for years. In programmes of rehabilitation, St Mary's alone cost £800 million or more. So at some time in the future, things will be all right, but how do we cure the present situation? My microbiologist, as I am proud to call him, advised me that effectively, 25 per cent of people carry MRSA. As the noble Lord, Lord Turnberg, said, it is in your nose but it is also principally in your armpits and, believe it or not, it used to be and still can be, under the wigs of eminent members of the legal profession, where it festers. But it does not cause any harm until it spreads. The skin shedding that takes place in hospitals, where skin mixes into the dust, is a method of transferring the disease.
	When we look at the hospital beds in the private and the public sector, they are all integrated in one way. We have 192,000 beds in the public sector in the United Kingdom; we need 100,000 more. Of those 192,000, it is sad to realise that only half are available for acute patients; many are for those with mental or learning difficulties, or for geriatrics. The occupancy rates are around 85 per cent or even more and, in some cases, over 100 per cent because of people going in and out twice in one day.
	We need new hospitals and improved facilities, and these will come over time. In the mean time, is it a question of cleanliness? Not necessarily, I am advised. Eighty per cent of all hospitals have MRSA. This is third-party advice, and I can never take third-party liability. So what is the problem? I am told that cleaning the hospitals could reduce that figure by 25 per cent, but the infection would still be there. The possibility lies in decontamination, which is what we used to get rid of cockroaches in ships, but even that was not very successful. Alternatively, you build a whole range of new hospitals and hope that in time the disease may not have mutated yet again.
	I am advised that there are different types of bug in different parts of the country, according to weather and people. If you need an operation, you might be better to go further away where there will be a different type of bug. It is no different to the different types of mosquitoes that can resist DDT.
	It is, if one thinks dispassionately, an interesting subject. There is no political division on it; none at all. I hope that the noble Lord, Lord Warner, will not attack those on our Benches for getting things wrong. If we cannot get the investment in the health service and in its restructuring, these diseases will fester and may even continue to expand.
	I wish the health service well; I feel sorry for all those who work in it who know that they need more facilities. We know that there is little that can be done in the short term, other than to be aware of the dangers, of which we must all be aware in the coming years.

Baroness Neuberger: My Lords, like other noble Lords I welcome and applaud the initiative of the noble Baroness, Lady Gardner, in calling for this debate. Also, like the noble Viscount, Lord Bridgeman, I was particularly moved to hear the personal story of the noble Baroness, Lady Pitkeathley, about her encounter with MRSA.
	The Secretary of State for Health is to be congratulated for his announcement on 5 November of a new target of halving super-bug infections by 2008. I am not normally one to be positive about targets because they tend to have perverse consequences. However, this target was announced at the Chief Nurses' Conference, and the new Chief Nursing Officer, as other noble Lords have already said, is a wonderful and remarkable woman. She is an old colleague and a friend to the King's Fund, where I was formerly chief executive. She has been given a remarkable target of halving that infection rate. I am sure that she will take a practical lead, as the noble Lord, Lord Hunt, has suggested, in issues of nursing style. She is fairly formidable and fairly practical—the noble Baroness, Lady Murphy, has already alluded to that.
	Many noble Lords who have already spoken have said much of what I wanted to say. However, some areas have not been touched on yet. Christine Beasley has taken on the need for training more than one million National Health Service staff in the area of infection control and hospital-acquired infections. Of course, that is only really the beginning, vast though it is.
	She will also have to look at other areas— particularly infection control in care homes because so many people in care homes go in and out of hospital. We know that much of the MRSA comes in from patients who have it already. At the moment, the Commission for Social Care Inspection looks at infection rates but not specifically at MRSA. Unless we look at the issue adequately in care homes we will not get some of the information that we need in considering how MRSA comes into our hospitals. That needs to be added to Christine Beasley's already vast list.
	As regards hand-washing, I should say to the noble Lord, Lord Turnberg, that, yes, the ladies do very much like the gels. The real problem is that they like them so much they keep disappearing. Therefore, there is a real issue in regard to hand gels because finding one when you need one is actually quite difficult.
	There is a separate issue about the washing of hospital uniforms in hospitals. It is a big problem in the NHS. We appear to be different from many other European countries and from much of the private and voluntary sector in that regard. Uniforms should only be washed in hospitals; they should not go home to domestic washing machines, which is still very much the practice in the UK. We do not know for certain whether this is one of the ways in which MRSA continues, but it is clearly poor practice because the temperature of domestic washing machines is not adequate. There are others who know far more about this than I do. I am told that the temperature of domestic washing machines is not adequate and that you can pick up infection as uniforms are transferred from home to hospital, back home again, and so on.
	I want to pick up on the issue of the private finance initiative and hospital building and design. The noble Baroness, Lady Masham, made an important point. There has been a great deal in the news about UCLH and the gap between beds, but this is a much broader issue. There were not enough adequate break clauses in the early PFI contracts and so, as design needed to change—for instance, to deal with hospital-acquired infections we needed to have more single rooms or greater distance between beds—there was not the capacity to break the contract and to say that there needed to be a change in provision.
	It seems to me that the Government need to look closely at that to see if we can renegotiate with some of the PFI providers to change the way in which the contract is delivered. We simply cannot have beds too close together or an inadequate supply of single rooms when we are seeing the trend of hospital-acquired infections still going up. Tony Harrison did some work for the King's Fund some years ago now and it was clear that the absence of break clauses made it difficult to allow for new design developments. It is clear that this is the case in this area.
	I have experience of cleaning staff from my time chairing an NHS trust. I was the chair of Camden and Islington community health services at the same time as the noble Baroness, Lady Gardner of Parkes, was chairing the Royal Free and the noble Baroness, Lady Murphy, was chairing one of the north-east London community trusts. We gathered together to bemoan our fate on many occasions. Against all instructions from on high, I resisted contracting out our cleaning services in the mid-1990s—not because there was a principled objection to it but because we wanted to keep our cleaning staff who were a key part of the teams, particularly when working with the elderly mentally ill and the very frail elderly, for whom we had some 600 beds. If we had contracted out, our cleaning staff would not have remained with us.
	It is vital that we are clear that it is not an issue of whether cleaning staff are contracted out or whether they are employed by an NHS trust; it is about whether they are included in the teams and whether they have some say in how the work is carried out. It is not adequate to say that nurses should manage cleaners. If they are given some responsibility, the cleaners themselves will take a lead. We still have a very hierarchical attitude in our NHS and the cleaning staff are seen as the lowest of the low. That probably does not encourage them to do the kind of job that we wish to see.
	There is an issue about the cleaning staff being part of the team, being included in the new training and being encouraged to make their views known, including when they see doctors and nurses not washing their hands and not carrying out adequate infection control procedures. They, too, can see what is going on. Anecdotally, many people will say that if you really want to know what is going on in a hospital, ask the cleaners. They see everything—although perhaps not always the dirt under the beds.
	I say to the noble Baroness, Lady Murphy, that things were quite bad in the 1980s and 1990s, but they were not that good in the 1960s and 1970s either. In the psycho-geriatric units, I certainly remember walking through absolute filth on the floors because no-one thought that those hospitals were worth bothering about. We have had a long spell of inadequate concern about cleanliness.
	Because we have no centrally held statistics on care homes and the admission of patients from care homes with MRSA or other hospital-acquired infection, we are missing a trick. I suspect that we need to merge the collection of data between the Commission for Social Care Inspection and the Healthcare Commission, who should look at the whole picture through a national review of the state of infection control in the NHS in England. That must include community services. Perhaps that would give us a clearer picture of what precisely is going on.
	I want to address the question of urgency. I know that before I came here your Lordships debated the issue of hospital-acquired infections on several occasions. One year ago, the Chief Medical Officer issued a plan, Winning Ways; Working Together to Reduce Healthcare Associated Infection in England. He admitted then that,
	"healthcare associated infection has in the past not been as high a priority for action as some other aspects of healthcare".
	That is right. The targets have been elsewhere, which has led to perverse behaviours. Admissions times have been terribly important, as have accident and emergency waiting times.
	The real problem is that there has been a lack of time for those concerned with infection control to wipe down mattresses between one person leaving a bed and another person coming into it. There has also been a paucity of hand hygiene agents. In that case, the lack of time is absurd.
	There has to be a decision about whether it is more important to get the infection rates down—in which case we will have to leave a gap between patients, which might mean that waiting times go up—or to keep the waiting times down, which will make it very difficult to keep infection rates down. We often have to make choices in public policy; the Government have to make that decision. It does not seem possible at the moment to have it both ways. We cannot keep waiting times and infection rates right down. Will the Minister address the issue of what choices the Government will make in that area?
	People are now talking the problem up and making it into a great national scandal. It is serious, but it is not a scandal. There are wonderful people working within the NHS and outside trying to make things better.

Earl Howe: My Lords, it has been a very good debate, and I congratulate and thank my noble friend Lady Gardner, who introduced it so authoritatively and so well. We have seen from all the contributions this afternoon what a salient and important issue hospital hygiene now is in the minds of the general public. When we speak of the cost of hospital-acquired infections we are talking not simply about money but, more significantly, about human suffering on a very considerable scale.
	Of course, it is possible to look at the statistics, as the Secretary of State did recently, and assert with complete accuracy that the incidence of hospital-acquired infections has changed very little over the past 10 or 20 years. Looked at alongside the record of other developed countries, the UK experience is not out of line. What that glosses over is the steep upward graph of the more serious, life-threatening infections such as MRSA. The rate of MRSA, in terms of numbers of patients affected, has more than doubled since 1997 and is still rising. Whereas in the Netherlands and Denmark the proportion of MRSA divided by non-resistant cases of staphylococcus aureus is a mere 1 per cent, here it is 44 per cent. In some hospitals in this country, MRSA is regarded as endemic. Quite rightly, therefore, the Government regard the fight against hospital infection as a priority.
	My noble friend was very balanced and fair in her approach, as she always is, and I shall try to emulate her. The first point that I need to acknowledge to the Minister is that the matter is clearly not one that the Government on their own can solve. However, there are surely some tests which the Government have to pass. One is that, in so far as they act as a facilitator of good practice, they should do so efficiently and effectively. The other is that they should not make life more difficult for those trying to deal with the problem in hospitals. We need to look rather critically at whether or how well Ministers and the Department of Health pass those tests.
	The striking thing, when one looks at the figures, is how widely the incidence of MRSA varies from hospital to hospital. Some trusts, such as those in York and Peterborough, do really well. Others, which it would be invidious of me to mention, do markedly less well. BUPA has reported that MRSA is negligible in its hospitals. It is unlikely that those variations are solely luck. A lot of work is going into research on the determinants of good performance in the area. We know, as the noble Lord, Lord Hunt, and others reminded us, that hand-washing by doctors and nurses is a major barrier to the spread of infection.
	It is not true that higher rates of infection are a simple function of the age of a building, however. The NHS has many older hospitals with creditable infection records, and many modern ones with a bad record. Yet it is generally agreed that the design of new hospitals—in which the National Patient Safety Agency now has a lead role—needs to take into account the desirability of single rooms and adequate isolation facilities. As a very general point, we need to factor into our thinking the fact that patients admitted to hospital are sicker and frailer nowadays than they typically were in the past, and the vulnerability of many to infection is that much greater.
	That much, perhaps, is common ground, but there are one or two areas where the Minister and I are likely to disagree. One area that particularly concerns me is the extent to which government target-setting for elective surgery has compromised the ability of trusts to control their rates of infection. I do not say, and do not think that we can possibly say, that the rise in MRSA is all because of targets. However, if we look at rates of bed occupancy, which directly reflect patient throughput, we see that nearly three out of every four NHS trusts with the worst rates of MRSA infection have bed-occupancy levels exceeding that deemed safe by the Health Protection Agency.
	It is no accident that the HPA has used the word "safe". It has not said "advisable". If a hospital exceeds a bed-occupancy rate of 85 per cent, it is behaving in a way that is not safe for patients. Professor Barry Cookson of the HPA has said that in terms. Both he and the NAO have pointed to performance targets as militating directly against good infection-control and bed-management practices. The NAO reported this year that 50 per cent of trust senior management had difficulty reconciling targets for in-patient waiting lists with the requirements for infection control.
	On one level, we could say that that is simply one of life's problems for hospital management to solve. In practice, however, so long as performance targets remain in place, any request from an infection-control team to close down a ward is almost bound to meet with a refusal. That is what the NAO reported in a number of instances. One has to ask why management should be put in that invidious position in the first place.
	A number of noble Lords have spoken about hospital cleanliness. A lot of nonsense appears in the press on the subject. There is no correlation, direct or indirect, between contracting-out of cleaning services and poor infection rates. Still less is there a basis for saying, as John Reid did the other day, that poor hospital cleanliness is really all the fault of the previous Conservative government. Many hospitals with contract cleaners have good rates of infection; some with in-house cleaners have a poor record. My own view, like that of the noble Baroness, Lady Neuberger, is that much depends on how cleaners are treated within the hospital, and if they are contract cleaners how that contract is managed.
	It is perfectly possible for the contract to ensure that cleaners who perform poorly are made to account for it, just as it is possible to give day-to-day authority over cleaners to nurses on wards. The trouble is that that is often not done, and accountability for the ward environment is fragmented. The arrival of modern matrons was meant to allow the withholding of payments to cleaners when performance was deemed to be poor. Perhaps the Minister will answer the question posed by my noble friend Lord Eden and tell us to what extent that power has been used. If it has not been used to any great extent, why not?
	Part of the difficulty of achieving cleaner hospitals is what many have seen as the decline in the ethos of cleanliness. Visitor access to wards is unrestricted. Staff uniforms are not laundered. Patients are moved between wards. Above all, cleaners are often marginalised rather than being made to feel, as they should be, a key part of the hospital effort. If cleaners need to feel a sense of ownership for a hospital and its patients, it is equally true that everyone else in the hospital, from the management down, needs to feel a sense of ownership for hospital hygiene. The NAO report of 2000 recommended mandatory MRSA surveillance in the hospital, specialty by specialty. That was seen as the only way in which clinicians would begin to take personal responsibility for trying to reduce infection in their own departments.
	Clinicians themselves wanted that type of reporting; but still the only mandatory requirement is for data to be collected across each hospital as a whole. That is a golden excuse for everyone involved to pass the buck because people do not see what happens in the hospital as a whole as being their problem. The NAO was very emphatic on that point, and I have to say that it is an omission that reflects directly on the Government. In the document, Towards Cleaner Hospitals, Ministers proposed the idea of "think clean" days. That approach is absolutely no good because it gives people the idea that hygiene is not something for which they need to assume personal ownership every day of the week.
	The NAO was also critical of the Government's snail-like behaviour in instituting the rapid review of new procedures and products, which was heralded last year in the department's document called Winning Ways. It took nine months from that announcement before the rapid review committee even had its first meeting. Meanwhile, applications had been made for a number of products and processes to be assessed for clinical and cost-effectiveness.
	If the Government were serious about having a rapid review process, why were they so slow off the mark in putting one in place? Why have they also been so slow to develop and produce a national infection control manual? Again, the department has received a drubbing from the NAO for the lack of progress on an initiative which it started to look at nearly five years ago and which could well provide an extremely valuable template for use by NHS staff.
	The list of sins unfortunately goes on. In 2000, the NAO drew attention to the lack of sufficient isolation facilities in NHS trusts. Nearly four years down the track, when the NAO looked again, it found that only a quarter of trusts had obtained the facilities they needed and nearly half had not even carried out a risk assessment. Isolation facilities have been a key part in keeping MRSA at bay in the Netherlands. Why did the Government not ensure with appropriate urgency that trusts were performance-managed on that issue?
	Over the past five years, we have seen a succession of launches and relaunches of government initiatives, including the creation of modern matrons, infection control gurus, patient environment action teams, Getting Ahead of the Curve, the clean your hands campaign, Winning Ways, Towards Cleaner Hospitals, and so on. But, so far as I can see, there has been no follow-up appraisal or audit of any of them.
	As I said earlier, HAIs are not a problem that government on their own can solve but, equally, government commitment to facilitating the solutions is indispensable. Why is it, for example, that the target date for placing a tub of cleanser beside each hospital bed is the middle of next year? Why do we not say that it has to be done straight away? The Government's target is to halve rates of MRSA in hospitals by 2008. That would be worth doing but, given that rates have doubled since 1997, that would simply put us back to where we were when Labour came to office. Is that target really ambitious enough?
	It may be that with recent announcements—or, rather, reannouncements—the temperature dial has finally been turned up a couple of notches. We now need to see greater commitment from government to the collection of data, the promulgation of practical guidance, a rapid review process for new technologies and the sharing of best practice. We need to give hospital management freedom to deal with a serious outbreak of infection without incurring penalties for non-performance of targets. We need to give control of hygiene on wards to the nurses based on those wards. The key to solving the problem of HAIs is not financial; it is managerial and cultural. It involves government and management and doctors and nurses working together in the knowledge that every day that passes without proper hygiene procedures means patients dying from this public health nuisance. That, indeed, is the justification for this debate. I very much hope that the messages sent to Ministers today are both loud and unambiguous.

Lord Warner: My Lords, I, too, congratulate the noble Baroness on securing this debate because tackling healthcare-acquired infections is a key priority for the Government. Indeed, I am leading on this particular issue within the departmental ministerial team and I chair a project team which meets on this issue weekly.
	I have to say that if that was the noble Earl, Lord Howe, being non-partisan and balanced, I would not like to get him on a day when he is not. If I may say so, I think that some of his speech showed how long his party has been out of government and how unaware it is of how difficult it is in a big, complex organisation such as the NHS to secure change.
	However, I am grateful for the many thoughtful remarks from noble Lords, and I want to set out how the Government are tackling the problem of healthcare-acquired infections, especially MRSA. I am particularly grateful to those who spoke from their personal experiences within the NHS.
	We find it a little difficult when we are given lectures on the problems of targets, waiting lists and the difficulties of the NHS when, as was acknowledged very clearly in this debate, it was the party opposite that cut the number of beds by 25 per cent. That is what happened. With regard to the noble Lord, Lord Selsdon, I am pleased to say that I always welcome a sinner who repents. I noticed that the noble Viscount, Lord Bridgeman, acknowledged some of these points. One does not just grow that number of beds overnight; it takes an investment programme and it takes time to produce that investment programme.
	If I may continue to work the noble Earl over a little, I thought that his remarks about the implementation of the cleanyourhands campaign typified the lack of reality. It takes time to put this system in place across all the acute wards in the NHS. It requires a management effort for that to happen. It requires supplies of the gel, supplies of the containers and the training of staff. We do not simply click our fingers and make these things happen in Richmond House. It may have been that way in the past, but it is not the way that we try to run the NHS at the moment.
	We know that much more needs to be done in this area, and we recognise that the recent NAO report on hospital-acquired infections contained some criticisms, as has been dwelt on today. But, as the NAO report also said, it is also worth recognising that our work in this area has moved infection control up the NHS agenda considerably. That was not mentioned by a number of noble Lords.
	The new Chief Nursing Officer—I share the high regard that noble Lords have for Chris Beasley—is building on the work that we have already done by leading our programme to improve both infection control and hospital cleanliness. I am sure that Chris Beasley will pay close attention to comments today about looking at nurse training curriculums, and I shall certainly be discussing this issue with her at our meeting next week.
	Let us be clear that these infections are caused by a wide variety of micro-organisms—often bacteria from our own bodies—and, unfortunately, not all hospital-acquired infections are preventable. Many factors contribute to the problem: for example, more susceptible patients, such as those with severe or chronic diseases, are being treated than ever before; and, at the same time, advances in treatment that improve patient survival, such as chemotherapy, can leave them more vulnerable to infections. My noble friend Lady Pitkeathley cited her own example in this area. Other factors, such as increasing antibiotic resistance, are also important.
	I assure my noble friend Lord Turnberg that we agree that there is no one simple solution to what is an extremely complex and multifaceted problem. But we believe that the risk of contracting these infections can, in part, be reduced by some relatively simple and effective infection-control measures. However, I emphasise that there are no quick fixes.
	As my noble friend Lord Hunt said, healthcare-acquired infections are an international and not just a UK problem. In the United States, Australasia and most European countries, including the UK, the percentage of patients who experience a healthcare-acquired infection come within a remarkably similar range. I acknowledge that there are some notable exceptions in some of those European countries but, across the whole of Europe, that is broadly the picture.
	Moreover, hospital-acquired infections are not a new phenomenon. While medical practice has changed and different micro-organisms have been involved, estimates that around 9 per cent of in-patients in England acquire an infection of some kind have not changed that much since at least 1980. I am grateful for the realism of my noble friend Lady Pitkeathley, whose graphic experience I witnessed when she was in hospital. She has brought home to us the realities of the difficult choices that NHS staff often face in acute hospitals.
	Comprehensive and reliable information on most hospital-acquired infections is not available. This Government were the first to act in 2001 to introduce mandatory surveillance for MRSA bloodstream infections. We are extending mandatory surveillance. The information on MRSA shows a slight but not dramatic increase over the past three years of 5 per cent. However, we are not alone in experiencing increasing levels of MRSA. The same problem has been occurring in Austria, Belgium, Germany and Ireland since 1999.
	Can we nail the figures on the risk of MRSA in NHS hospitals? We estimate that MRSA affects about 0.3 per cent of patients; that is, three in 1,000. Of course that is three too many in every thousand and we need to reduce it. However, we should be careful not to exaggerate what is a serious problem to such an extent that we alarm patients and the public and make them afraid of going into hospital to seek the treatment that they need.
	MRSA has become more of a problem in the UK for a number of interrelated reasons. They include the fact that the strains responsible for most infections in the UK are particularly well adapted to spreading between patients. MRSA was relatively uncommon through the 1960s and 1970s. A few more appeared in the 1980s, but the problem exploded in the mid-1990s when particular epidemic strains of MRSA became established in hospitals in the UK.
	I have to tell the noble Earl, Lord Howe, that the major surge was between 1993 and 1997. The epidemic strains have the property of easy transmissibility and they readily spread between patients. Moreover, they have the capacity to cause serious disease which means that they are virulent. These are the ones that now represent over 40 per cent of the staphylococcus aureus causing bloodstream infections in England.
	MRSA infections are not spread, as a number of noble Lords have said, equally across the NHS. One fifth of trusts account for almost half of all MRSA bloodstream infections and around 80 per cent of all MRSA cases are concentrated in around 50 per cent of hospital trusts. We will be working closely with those who have the greatest problems. We want to help them to learn from those who have the better track records in this area.
	While we know that not all these infections can be prevented, we are acting on this important patient safety issue. We are committed to being completely open with the public about the matter and have published the level of MRSA infections in every NHS trust since 2001. We are working in partnership with patients and their carers; for example, Ministers have met the patient MRSA support group and hope to work with it in the future.
	The noble Baroness, Lady Murphy, drew attention to the damage done to NHS capacity in the 1980s. As I said earlier, I welcome repentance in that area from the Benches opposite. That is why we are having to create the extra capacity needed to ensure that better patient care is available. By 2007–08 public expenditure on the NHS is set to rise to £90 billion a year, compared with about £33 billion a year in 1997. We are putting more doctors and nurses and 40 new hospitals in place and there are still about 30 to come. Those improvements will help us to reduce healthcare-associated infections, as I believe the noble Baroness, Lady Murphy, indicated.
	We know that there is no quick fix. I am grateful to my noble friend Lord Hunt for his support for our plans for reducing infection rates, as set out in the Chief Medical Officer's document Winning Ways and our 2004 document Towards cleaner hospitals and lower rates of infection, published in July. We are actively implementing this programme; for example, we are providing £12 million over three years to support the work of hospital clinical pharmacists who are monitoring compliance with antibiotic prescribing policies.
	I am grateful for the support from the noble Baroness, Lady Murphy, for the major new initiative that we have taken in the introduction of our only—I emphasise "only"—new target which is halving MRSA bloodstream infections by 2008. We know that having a target ensures that the issue is given priority in the NHS and the NAO report, mentioned by noble Lords, indicated that the introduction of mandatory MRSA surveillance raised the profile of infection control with senior managers. We believe that the new target will act in a similar way.
	A number of noble Lords have drawn attention to the importance of hand hygiene. It is an important part of infection control and in September we funded and launched what we believe to be the first ever national hand hygiene campaign. The cleanyourhands campaign is based on a thorough, successful pilot study undertaken by the National Patient Safety Agency. I pay tribute to my noble friend Lord Hunt for the leadership that he has shown in that area. That evidence-based campaign is tackling what has been an intractable problem for healthcare systems worldwide and its impact on infection rates will be carefully evaluated. It is stopping journeys across the ward to wash hands, as my noble friend Lord Hunt described so graphically, by putting alcohol gels easily accessible at all bedsides in acute hospitals.
	I can assure my noble friend Lady Pitkeathley that we are also taking a proactive approach to research. We shall host a science summit later this month of leading scientists from home and abroad to consider how their research can influence our healthcare-associated infections programme. That will identify work that has the potential to be applied shortly and new research priorities. Money has been identified and our research programme will be expanded as proposed in Winning Ways. I can reassure my noble friend Lord Turnberg that we want to find a speedier test for establishing MRSA in patients, but that is not an easy thing to achieve. We need much help from scientists in this area.
	We are actively supporting NHS staff to achieve those changes; for instance, the new audit tool developed with the Infection Control Nurses Association will help acute trusts to monitor and to improve infection control. That will help NHS staff to assess compliance on policies such as hand hygiene, decontamination of patient equipment, linen and waste handling and clinical practice. I can tell my noble friend Lord Turnberg that we are looking at the evidence on agency staff, which is fairly complex to pin down.
	Another area where we are helping the NHS is in assessing products that claim to help to control and to prevent healthcare-associated infections. I have a steady postbag from people offering me every conceivable answer to this problem. That is why we asked the Health Protection Agency to establish a rapid review panel for such products. Perhaps with hindsight the title of that panel was a little misguided. The panel's remit is to provide a prompt assessment of new equipment, materials and other products or protocols that may be of value to the NHS in improving hospital cleanliness, hygiene and infection control. It is true that the first results have taken some time to emerge from the panel, but it is under no misapprehension that we expect the process to be carried out more speedily. The first results from the panel were released this morning and will be of interest to the NHS. They were actually covered on the ITN news this lunchtime. The silver-coated hydrogel catheter may be of particular interest. We hope that the second wave of results will be available before the end of this year.
	Our programme is one in which local action is crucial. The requirement in Winning Ways for each trust to designate a director of infection prevention and control is helping to change the culture so that infection control is everybody's business. That is a critical point to be made throughout the NHS. There is not one group of staff who on their own will be able to change the situation. The directors report directly to the chief executive and the board and will thus be able to bring about local change. Let me assure the noble Lord, Lord Eden, that we shall be looking to trust boards and chief executives to exercise leadership and to change the local culture in this area and to get everyone to include infection control on his personal development plan.
	I can also tell the noble Lord that off the top of my head I can think of two specific examples where the contractors have been changed—the Oxford Radcliffe Hospitals NHS Trust and the Chelsea and Westminster Hospital. I think that there may well be other hospitals which have taken that decision.
	The noble Baroness, Lady Masham, and the noble Baroness, Lady Neuberger, said that the new Chief Nursing Officer had made clear that we will want to improve infection control training for all staff. We recognise that this is a top priority and that we are engaged on a major change programme. We are talking about 1.3 million staff in the NHS. Again, I gently remind the noble Earl, Lord Howe, that these things take time to organise and to put into practice. He may have forgotten that from his time in government.
	We are also working to improve both infection control and cleanliness, since even in the absence of unequivocal scientific evidence, common sense suggests that there is a link between the two. Due to a drop in investment for cleaning in a previous period, between 2000 and 2003 the Government have invested an additional £68 million in a nationwide hospital clean-up campaign and have initiated a programme of unannounced visits by independent teams. Patient Environment Action Teams assessments, which involve patients' representatives, continue today and their results are used to help determine a trust's star rating.
	The cleanliness figures from 2003 show that 78 per cent of trusts were assessed as "good" on cleanliness and 22 per cent as "acceptable". That shows a significant improvement on previous periods. The noble Earl, Lord Howe, invited me to disagree with my right honourable friend's remarks about contract cleaning. I think the point that my right honourable friend was making—and I always hesitate to disagree with him—is similar to the point touched upon by the noble Lord, Lord Hunt, that the fact of contracting out of cleaning in a past era drove down the investment in this particular area. That is an important issue which we need to get to the bottom of.
	I accept that the PEAT scores suggest not a great deal of difference between the performance of trusts which have contracted out cleaning and those with in-house contracts. Some contracts are not very smartly set up to ensure rapid response where there are particular problems. Some have operated in a way that excludes nurses from the agenda of remedying deficiencies in the cleaning arrangements.
	We have issued a cleaning manual to the NHS, setting out the best ways to clean hospitals. That will be updated when the results of our research on new cleaning methods and technologies become available. We will provide recommended cleaning standards and minimum cleaning frequencies to achieve these standards and ways of measuring them. I think that that will help both in-house teams and contracted out services to perform more effectively.
	A number of noble Lords have mentioned—I thought on one or two occasions not totally kindly—our launch of the new matron's charter. This document will help modern matrons and others to raise standards. It sets out 10 key commitments that everyone can sign up to, no matter how cleaning services are organised. It was written with the support of seven partner organisations, including the Royal College of Nursing.
	We will also be supporting a series of activities aimed at ensuring that cleanliness is at the forefront of everyone's mind, for example, involving frontline staff in a "Think Clean" programme. I do not think that this initiative is about a one-off event; it seeks to establish in people's minds that cleaning is a top priority in the way they do their job. We are developing training materials in this particular area and will be working with the professional bodies on the whole area of the curricula of undergraduate and postgraduate training.
	It has been suggested that our success in treating more patients has impacted on our ability to control infection rates. A number of trusts—Sheffield Teaching Hospitals NHS Trust, Harrogate Health Care NHS Trust and Taunton & Somerset NHS Trust, to name a few—have achieved waiting list targets and maintained low rates for MRSA. The two are not incompatible.
	This is a local decision. It is up to people locally to manage their services in the most effective way. Our job is to establish the right direction and to invest in the quality of local leadership. We have put in place the new Directors of Infection Prevention and Control. We think that they will provide good advice. We have been absolutely clear on our view that clinical priorities and clinical need should take precedence and guide the actions and decisions of those deciding on the closure of beds, wards and hospitals. We have not deviated from that position. People must make their own judgments. My noble friend Lady Pitkeathley put the matter very well. She said that in some cases you are faced with situations of real emergency that you have to make decisions on and you have to balance that against some of the issues around infection control.
	In conclusion, we are determined to reduce healthcare-associated infections by creating extra capacity in the NHS and implementing an evidence-based programme to identify the actions which will make a difference and drive these forward by setting clear targets and offering support to trusts which need help.

Baroness Gardner of Parkes: My Lords, I thank all noble Lords who have taken part in the debate. I am most grateful to them. We have only two minutes left so I can say very little. We have had some excellent contributions. I thought that the Minister gave a very cautious welcome to the new idea which the ITV news today implied was going to solve the whole thing in a puff. So I am rather disappointed that he still seems to think there is a long way to go. But every step forward in the battle against MRSA is very important. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.

Regional Agencies and Bodies

Lord Hanningfield: rose to call attention to the current status of the regional agencies and bodies, and to the case for returning their responsibilities to elected local government; and to move for Papers.
	My Lords, I am pleased to have this opportunity to raise an important and significant issue that goes right to the heart of how we in this country are governed.
	It is clear that both by stealth and by more transparent means the Government have systematically stripped away powers from our democratically elected local government and placed it in the hands of an unaccountable, unelected, regional quangocracy. This is a regrettable and unsustainable development. I should like to go more into that issue.
	The timing of this debate could not be more appropriate. Less than a month ago the people of the north-east overwhelmingly rejected the Government's proposal for a regional assembly in that area. That was not just a rejection of a regional assembly, it was a rejection of the Government's entire regional agenda. Indeed, even the Government realised that there was no support for regional government anywhere in the country when they thankfully pulled the plug on the other two referendums in the north-west and Yorkshire and the Humber.
	As an aside, I add that the entire exercise seemed to have cost around £10 million, which was enough to pay for 500 nurses or 350 policeman, when I, and I think others, had said that it was a waste of time anyway.
	However, today I am trying to help the Government. I hope the Minister will respond in that way by saying where we might go in the future. Indeed, in initiating this debate I am keen to provide the Minister with an opportunity to set out where the Government go from here on the whole approach on regional issues.
	Do the Government intend to carry on introducing more and more regional bodies and agencies against the seeming will of the people; or do they now recognise the strength of local government and the fact that people would rather have local people, who are accountable and democratically elected, representing them and taking decisions on their behalf?
	Noble Lords may ask why this matters. That is a pertinent and important question and one that deserves a full and—I hope—considered response by the Minister. However, rather than try to answer the question myself immediately, I shall briefly cite the words from a letter to a newspaper last week. It read:
	"We have, and now will continue for some time to have, regional government conducted in piecemeal fashion by civil servants, quangos and next-steps agencies appointed by and responsible to ministers, with minimal accountability to the regions they serve. In voting against what they perceive as bureaucracy, the people of the North East have in fact entrenched it".
	The Minister may be aware of from where that quote came, but for the benefit of the House, those words were penned by Sir Jeremy Beecham, Labour leader of the Local Government Association. It is striking that such a concern should have been expressed by such a senior figure in the Labour Party and one of the most senior Labour people in local government. Perhaps the Minister could enlighten us about whether that sentiment is shared equally by colleagues in government. Although Sir Jeremy and I come from very different angles on the issue—he is in favour of regional government and, as most people will be aware, I am pretty much opposed to it—his point is valid and needs to be addressed.
	We are now left with no chance of regional assemblies, certainly not for the foreseeable future, and yet with a multitude of agencies and bodies intended to be controlled and scrutinised by those assemblies but now free and unhindered to go their merry way with virtually no checks or balances. As I have mentioned several times, the areas of the so-called regions are not really in keeping with the facts on the ground, especially in England.
	There is a clear democratic deficit that is now evident in a range of services that previously rested firmly in local government. Indeed, the Government have been busy in recent years removing powers and responsibilities from local authorities—we saw this in the recent planning Bill—to place them in the hands of unelected regional placemen and bureaucrats. We now have unelected and undemocratic regional housing boards, unelected and undemocratic regional fire management boards, unelected and undemocratic regional cultural consortiums, unelected and undemocratic regional development agencies, unelected and undemocratic regional observatories and unelected and undemocratic regional public health observatories.
	If that was not enough, we have all these Government departments falling over themselves to get in on the regional act with bureaucratic regional offices. We have regional public health groups; regional rural affairs forums; the Housing Corporation, with four regional offices in England; the University for Industry, with an office in each region; the Sector Skills Development Agency; the Learning and Skills Council, which established a network of regional directors in January 2004; and recently, regional emergency planning services.
	As the leader of a large local authority, I am especially concerned about the regional ideas that the Government have about procurement. My county, Essex, is supposed to co-operate with Norfolk, when all our procurement issues are relevant to London boroughs or Kent. That is a costly exercise as well as an undemocratic one.
	No one has voted for those things; in fact, in the north-east, they voted against them. No one has asked for them to be established and no one is really sure why they are necessary and what they are going to do. It would be much best left to the counties, districts, local authorities, London boroughs and unitary authorities to get on with their job. Perhaps the most galling for all of us is the continued existence of the unelected regional chambers—rather bizarrely, after the events in the north-east, some of them are called regional assemblies.
	The Minister for Local Government said in another place:
	"The Regional Chambers are . . . not agencies or arms of the Government. . . . The Office of the Deputy Prime Minister does not hold information on the staffing and infrastructure costs incurred by each Chamber".—[Official Report, Commons, 5/5/04; col. 1604W.]
	However, I can reveal to your Lordships that careful analysis of the chambers' annual reports, corporate plans and accounts has revealed that the eight regional chambers in England spent £23 million in 2003–04. That expenditure is not accountable to local people. There are no direct elections to those bodies. There are no means to challenge their decisions or expenditure. One-third of the chambers are made up of community stakeholders, who have no pretence of having any democratic mandate whatsoever. Yet they vote on issues in the chambers and can change the decisions of those chambers against the political balance, as I am only too well aware in the east of England, which means that decisions are made without any democratic accountability.
	Those chambers possess a variety of powers through various Acts of Parliament. No doubt the Minister will deny that they have many powers, but we shall come to that in a moment. Those powers were granted on the presumption that elected regional assemblies would follow but we now know that that will not happen. Something must therefore be done to redress that democratic deficit and make certain that decisions are taken by democratically elected people. I hope that the Minister will agree that that issue needs to be addressed urgently. Obviously, the Government should consider what has happened because of the recent vote in the north-east, with no possibility of any regional assembly being created for a long while.
	I know that the Minister would like to get up—I am surprised that he has not so far, but he will soon—to say that many Conservatives are actively involved in those assemblies and chair some of them. However, now that each chamber has some statutory powers, such as planning, people feel that they should be involved in the decisions taken, even if they do not wholly approve of them. As the Minister has said several times, those bodies are voluntary—perhaps we will talk about that later. I know that several local authorities are wondering about not participating in them, although they would still have to be involved in planning decisions, because that is now the law of the land. There is debate among local authorities about the desirability of participating in those regional forums.
	Given the choice, we would all scrap those bodies and return the powers to local councils. We have heard many times that the Conservatives created the Government Offices for the Regions. However, I remember talking to John Gummer when he created them. They were created to be an arm of the Civil Service. We have always had government departments sited out of London and they were put together to make things work better. They were there to establish a light-touch, interdepartmental co-ordination and nothing more. In the eastern region, we had a highways office in Bedford, an agricultural office in Cambridge and an educational office someone else, which were brought together. Those offices had been there for many years and were put together not to pervert local democracy but to make things work.
	Even the Government admitted in a Cabinet Office report:
	"among the array of separate regional and sub-regional bodies, the purpose and remit of some of these can be unclear, incomplete and sometimes overlap with others without clear reason".
	The running costs of the Government Offices for the Regions for 2003–04 was £124 million, compared to £86 million in 1997–98, a rise of 44 per cent. The programme expenditure budgets have similarly grown in size, with ever greater interference in the work of local councils.
	I cannot remember a time when councils could get on with delivering quality public services to local people without some kind of government interference. I admit that my government did plenty of that. Fortunately, Conservatives have seen the light. I thought that the Labour Party had when it was in opposition, but governments tend to want to get too involved with local government and not let it get on with the job. That is evident from what we have seen in the past few years.
	The fact remains that there is a remoteness of regional government. As I said, if one wants regional government, let us consider most of Europe, where the regions are smaller than the average size of counties in this country. It is only in countries such as Germany that they are as big—and the Lander, were ex-countries anyway, such as Bavaria or Hanover—and in Austria and Spain. The regions of all the other countries in Europe, including France, are smaller than most of our large counties.
	There is no evidence that the regional government that the Government proposed would have delivered any services better than democratically elected local government—county councils, district councils, London boroughs or unitaries. There was no reason to create artificial areas rather than our existing natural areas. Genuine decentralisation should be to local councils, not regional quangos and so on. Regional government is distant from local communities. In my county of Essex, we have 11 district councils and about 30 communities. It would be much better if more decisions could be taken in each community, so that people could judge what they wanted for themselves. It is much better to decentralise downwards than to centralise upwards.
	The result in the north-east is a clear mandate that the people of this country do not want regional government. I hope that the Government will accept that now and try to remedy the situation. I hope that we all want to roll back centralism and let local people make their own decisions. I ask the Minister today to make a commitment on behalf of the Government to abandon the regional idea and give powers back to local government, where they rightly belong. I beg to move for Papers.

Lord Rodgers of Quarry Bank: My Lords, when the outcome of the north-east referendum was declared and the Government made their statement, the noble Baroness, Lady Hanham, was entitled to say "I told you so". The Conservative Front Bench is entitled to say that once again in the context of this debate.
	Unlike the noble Lord, with his distinguished record, my direct experience of local government was brief. For four years, I was a councillor in the old St Marylebone Borough Council, before it merged with Westminster and Paddington, and the arrival of the GLC. But as a child I learnt to read on the proofs of the Liverpool council agenda when my father was a local government officer. I mention that only to establish my modest credentials.
	I want to look at the history of the north-east referendum and its lessons. The outcome had been anticipated in the closing days of the campaign, but the majority "No" vote was much larger than expected, and on a respectable 48 per cent of the electorate. For those of us who hoped that the north-east would choose the limited regional government on offer, there is no point in ducking the result. It was my own strong preference, as it had been for 40 years.
	In 1964, when I was a junior Minister in the Department of Economic Affairs (DEA) in Harold Wilson's new government, I began to set up the regional economic planning councils and boards. They were to cover the whole of England; Scotland and Wales made separate arrangements. The momentum grew from the problems of the north-east. I was the Member of Parliament for Stockton-on-Tees and fully aware of the high, persistent unemployment that had characterised the 1930s with the so-called "distressed" areas. Now the long post-war years of economic growth had come to an end, and we were again comparing between the relatively prosperous south and the accelerating decline of the north.
	George Brown, my ministerial boss, Deputy Prime Minister and First Secretary of State, a role parallel to that of John Prescott, was preoccupied with the national plan and prices and income problems. I was allowed a good deal of freedom to put the regional structure together and commend the appointments of the economic and planning councils. Within 18 months, my task was almost complete, despite the scepticism of the Treasury, the hostility of the Board of Trade and the jealousy of the Ministry of Housing and Local Government. They had virtually no executive powers, and there was no absence of democratic accountability; but it was, I thought, the tentative beginnings of regional government, and the north-east would always take the lead.
	Even before the end of the first Wilson government, regional planning lost momentum. Ministers began to worry about urban decay in London and major cities, and serious pockets of economic, industrial and social deprivation, even in prosperous areas. There was no real enthusiasm among most Cabinet members. In 1970, there was a change of government. Regionalism persisted but the possibility of regional government drifted away. It was almost a whole generation before the Labour Party began to take the regions seriously again.
	I tell this story because it is relevant to the events leading to the referendum. Clearly, there was a lot of cross-voting in the region, which is still overwhelmingly Labour in parliamentary elections. Some Liberal Democrats, too, may have voted "No", despite a firm and longstanding commitment to regional government.
	It would have been entirely legitimate for the noble Lord, Lord Hanningfield, to score points against the Government but I doubt whether the outcome of the referendum will have any significant influence on how votes fall in the general election. The referendum was a special event, a one-off. But, as the noble Lord, Lord Hanningfield, said, there are certainly lessons about government—at all levels—and what the public and voters want. Those who applaud the verdict may not be wholly comfortable about the reasons.
	Voters in the north-east referendum do not appear to have been enthusiastic about local councillors or anticipated regional councillors. That may be unfair, as most work hard and well, but voters did not want more of the same, with councillors seen to be going from one committee to another, collecting their expenses. There was scepticism about costs, including capital costs, given the building costs of the new Scottish Parliament—although it may be a fine building—and other recent capital projects. Taxpayers did not believe that the running costs of the assembly would be transferred from Westminster to the north-east with a zero net outcome.
	But the central question was: what was the assembly for? The voters had not been convinced by an adequate reply. The people of Tyne, Wear, Tees and adjacent areas came together in the 1960s and 1970s because they shared in longstanding economic and social problems. But that political imperative is perceived to have declined. Among 100 constituencies with the worst unemployment, there are only six in the north-east. There is serious unemployment and deprivation—for example, in South Shields, Middlesbrough and Tyne Bridge—but, broadly, the north-east feels that it shares in Britain's current impressive prosperity. There is confidence and optimism, and the cloth cap has gone.
	In passing, I mention in particular the regeneration of the Tyne, which has been a great success. The new music centre, The Sage, in Gateshead, with its concert hall designed by Norman Foster, has just been opened. The Baltic arts centre has already been working for several years.
	I hear the argument in today's Motion that the responsibilities of non-elected regional agencies and bodies should pass to existing local authorities, as regionalism has, apparently, collapsed. However, we should not take it for granted that voters would trust in the transfer of those powers, when local government is so often unpopular. Nor am I convinced that the functions of such bodies are necessarily appropriate to the locality, rather than to the region.
	When the Government decided to pursue regional government, they adopted a modest and limited proposal: they would give the regions only the minimum powers to justify their creation. The Government did not choose, as they should have done, the optimum powers that would be most effective in serving the regions. It is not surprising, even in the north-east, that there was no enthusiasm for change, in the absence of any new political imperative. Next time—a time will eventually come—there must be a real agenda of substance, demonstrating that cost-effective powers can be transferred from Westminster to the regions to meet the relevant needs of the regions.

Baroness Byford: My Lords, I am grateful to my noble friend Lord Hanningfield for giving us a chance tonight to debate this important issue. As the Minister will know, there can be nobody in the House who supports local government at the lowest level more than I. My rural brief is part of my Defra brief, and it is important that government is as local as it can be. The Minister will not be surprised to hear that I said, "Thank goodness", when I heard that the north-east had given a big thumbs-down to what was being proposed up there.
	It was interesting to hear the noble Lord, Lord Rodgers of Quarry Bank, say that he thought that the assembly would not have had enough powers. I suspect that, even if more powers had been on offer, the electorate would still have said, "No". That is something to which we will, no doubt, return.
	Three quarters of the 48 per cent who voted in the north-east said "No". I believe that people considered that the assembly would be a waste of money. The exercise of organising the referendum cost £10 million—how very much better that money could have been used.
	The regional development agencies are still there. They were created in 1998. I come from the east Midlands area, which links Lincolnshire, Leicestershire, Derbyshire, Nottinghamshire and, I think, Northamptonshire—I hope that I am right about that. People in places that I visit in Lincolnshire are still concerned that, within the RDA area, they are the losers. The big conurbations tend to command more of the money because that is where more of the electorate lives. The role of the RDAs ought to be re-examined. They cost £1.8 billion a year and employ 1,800 staff. Yet, as others have said, we still have eight Government Offices in regions outside London.
	One of my questions for the Minister—he will be grateful that I do not have 17 on this occasion, unlike the previous time that I debated with him—is whether the Government have considered making better or slightly different use of those eight Government Offices, after what happened in the referendum in the north-east. Do the Government envisage that they will continue as they are? Will the Government consider examining the RDAs as they are now? As my colleague said, they are unelected, unaccountable and made up of a variety of people, including councillors, trade unionists, cultural networks, pressure groups and others. Will the Government question the purpose of what they do?
	One of the aspects that worries me is on the planning side. There are planning issues that perhaps need to be considered on a basis wider than county level. That is just one of the minor issues, but there are issues about the responsibilities of the RDAs. Could they be transferred to the Government Offices? Have the Government considered that?
	As my noble friend said, the Government Offices cost £124 million in 2003–04, compared with £86 million in 1997. One has to wonder what on earth they do and what extra responsibilities they carry that have made that figure go up so radically. Did they—do they still—overlap with the RDAs? Are there things that could be separated from them?
	As I said, I am a great believer in local government. I was born in the village in which I live. My brother is a parish councillor and a county councillor. My other brother—sadly, he has died—was also a county councillor. Most of my early working life—as a volunteer in this instance—was with the WRVS in Leicestershire. We were very involved in local community activities and did a tremendous amount of work across the board. The one thing that came out so clearly was the value of community living and community links, in addition to the services that we provided. When I talk to people who live in towns about what goes on in villages, they say, "You are so lucky that you still have a community spirit". I worry that that will be dissipated, if the Government do not rethink where we are going.
	The Minister and I have debated the role of parish councils at some length. I know that the Government are concerned that, in some areas, parish councillors are thin on the ground and parishes struggle to get people who are willing to stand. For me, that is no answer. I am sure that the lowest electoral level is where many decisions could be made.
	Planning is still a worry for many in the smaller rural areas. In some villages, a large amount of growth has been allocated. However, in some smaller villages, there is a possibility that two, three, four, half a dozen houses could be approved to become affordable housing. Sometimes, that can be difficult. The parish council will suggest it, but it will be overruled elsewhere.
	I toss two suggestions to the Minister. The first is that the Government should consider declaring that ex-farm buildings could be treated as brownfield sites. That would help to relieve matters and encourage some sort of new build. Secondly, I encourage the Minister to consider ways to continue to support post offices in the rural network. They are a hub. In fairness, I acknowledge that the Government have put some money towards that.
	As noble Lords will gather, I believe very much in local government, but my noble friend's asked the Minister the right questions: having had the result in the north-east, where will they go from here and what will happen? Obviously, the Government set the ethos as regards the services that should be provided locally and then pass responsibilities down—at the moment predominantly to county councils or metropolitan districts. The one thing that has worried us over the years and is still relevant is that, although local communities are willing to undertake the work, there must be sufficient funds to ensure that they can carry out their extra responsibilities properly.
	One of the things that will exercise the mind of electors when they go to vote in May will be the huge increase in the local government taxes that they pay. One of the difficult things that local councillors have to explain is that they are carrying extra responsibilities as a result of national policies. They must carry those responsibilities out and, at the end of the day, somebody has to pay for it.
	There is an opportunity here for the Government to think again and determine whether they can see ways of returning more responsibility to the local level—be it at county, district or parish level. I hope to encourage the noble Lord to consider that. In humility, perhaps I may suggest that that could be done in the most flexible way. We sometimes become too rigid.
	I shall give one small example of post offices. In some villages, it has become very difficult to maintain sub post offices. Indeed, last year in Leicestershire, a church opened a sub post office on Tuesday and Thursday mornings for only three hours. That may be just a drop in the ocean, but it is much better to maintain something that is valued not just for the service that it provides, but also for the social link and community work in which it is involved.
	I hope that the Government will stand back, will not sulk—I know that this Minister will not because he is far too practical—will reassess where they are and will address where we should go in the future. I thank my noble friend for this opportunity.

Lord Greaves: My Lords, this is the first time that I have had an opportunity to say anything about regions since the ill-fated north-east referendum. If Members on the Conservative Front Bench are saying to the Government, "I told you so", I certainly also say, "I told you so". The referendum was a complete botch the whole way through and the Government got exactly what they deserved.
	I kept well out of it. I took the view that it was not my job to interfere with what my colleagues in the north-east might or might not wish to do. But had I been an elector in the north-east, I would have voted "No". One of my reasons for that is that I am a passionate believer in devolution to the English regions, particularly to those regions in the north of England. Devolution to the north-east was simply not on offer in the referendum that took place. I disagree with many of my colleagues on that but, at heart, I think we agree on what we want to see.
	It is interesting that not very long ago regions were at the top of the political agenda and many noble Lords attended debates in this House. Such debates have obviously dropped to the very bottom of the agenda now judging by the number of people who wish to speak today. However, for some of us the regions will remain an important political issue, which we will keep on the agenda. I hope that we will continue to fight hard for proper elected regional government in England, exercising powers that are devolved from Westminster and Whitehall and not taken from local government. I should remind the House that I am an elected member of Pendle Borough Council.
	Originally, there were going to be three referendums—in the north-west, the north-east and Yorkshire/Humber. The Government dropped two of them. They did not dare to go to the polls without an all-postal ballot because they thought that no one would be interested, which I think has been proved wrong. Two of the referendums were scrapped supposedly because the Electoral Commission thought that it would not be safe to have all-postal ballots in Yorkshire and the north-west.
	Your Lordships will know that I am fairly strongly against all-postal ballots. In fact, I am very sceptical about widespread postal voting of all kinds because it is wide open to fiddling in all sorts of ways, as I have experienced. My noble friend Lord Roper on the Front Bench is laughing. So, to be absolutely clear, perhaps I should say that I have been on the receiving end of it.
	The idea that people would spend a lot of time rigging a poll on regional government was nonsense. The elections that people rig are marginal seats, particularly in local government. There, incomes or councillors' allowances of £5,000, £10,000, £20,000 or more a year might be at stake, which is very important, or there may be other reasons for someone desperately wanting to be a local councillor. A poll may be rigged by getting perhaps only 100 or 150 votes in illegal ways, thus changing what happens in a ward. The idea that that could be done across a region was always rather fanciful.
	The real reason the referendums were scrapped was that the Government believed, on the basis of private polling and other measures, that they could not win a referendum in the north-west or in Yorkshire. They did believe that they could win in the north-east because early polls suggested that that would be the case. Interestingly, the more that people found out what was on offer and what was going to be done, the fewer the number of people who were going to vote for it.
	I agree entirely with my noble friend Lord Rodgers of Quarry Bank who, in what I thought was a most distinguished speech, pointed out that the main reason people were not sold the assembly in the north-east was that they thought that there was nothing on offer worth voting for. There were other reasons, such as the poor campaign. I have friends in the north-east who wanted to campaign for the "Yes" vote, but they found that it was very difficult to do so as part of the very centralised, tightly organised and fairly incompetent campaign that was run. There was also a lack of enthusiasm on the ground in some areas where the existing local government structure was to be torn up and replaced.
	It is interesting that that does not appear to have been a major factor in the proportion of voting in the referendum. There is not a correlation between the proportion of voting against and the type of local government. The real correlation that seems to exist is that the further one moved away from Newcastle, the more people voted against. So the highest proportions were in places such as northern Northumberland, which is two tier, and Cleveland in the south, which is already unitary.
	It is an interesting thought that people really were not concerned about decision making from London; they were concerned about decision making from the main city within a region. Living in a peripheral part of the north-west, I think that that would have happened in the north-west as well.
	The question is: will regions go away? This is where I differ from the noble Lord, Lord Hanningfield, and the noble Baroness, Lady Byford. I do not think that regions will go away. It is true that there is a proliferation of bodies in the regions; some of which perhaps could be rationalised, some of which could be done away with. There are government offices, regional development agencies, boards, agencies, trusts, partnerships, various corporate charities, networks and foundations—a whole plethora of new Labour "quangocracy" is taking over this country at regional, local and every level.
	Nevertheless, the question we ought to ask is whether regions should go away. I accept that in the south-east there are problems of defining which regions there should be, but in the rest of the country there is no doubt that regions exist. The north-west exists. I know that the noble Lord, Lord Waddington, will not agree with me on that as we have had many debates.
	But there is no doubt whatever that regions exist in those areas. There is a legitimate level of decision making at that regional level which is greater than the locality. If it is not exercised at regional level, it will be exercised here in London. I believe that even if they are unelected and even if it is a matter of bureaucracies, the people making decisions in the north-west will make better decisions if they live and work in the north-west than if they live and work in the south-east and in London. That is a difference of opinion, but to me it is fundamental.
	What is the way forward? Some of my Liberal Democrat colleagues have suggested that perhaps we should convene a new convention of the three regions in the north, which should come together on the lines of the Scottish Convention and decide the way forward. My view is that that is at least premature and would not have any value at the moment. We have had conventions—we had a convention in the north-west which came up with proposals for much better and stronger devolution and regional government than the Government were prepared to concede. If there is not the political will in the Government, going through that whole exercise again would be a waste of time.
	In addition, we have to rethink ourselves. I agree with the noble Baroness, Lady Byford, that if we had referendums now in any of the northern regions, even for the sort of proper regional government that I and my party would like to see, we would find it very difficult to get "Yes" votes.
	We have to go back and rethink this from scratch. In my view, the basic principles are that decision-making should take place at the lowest appropriate level. However, it is clear that the Government do not adhere to that policy, given how they are putting local government into an ever tighter stranglehold of control almost week by week. They try to tell people what to do and to micro-manage the whole of the public sector in the country through the complex new quangocracy which has been set up. We do not agree with that. We want to devolve far more power to the local level.
	Surely one of the preconditions of getting people to accept, support and be enthusiastic about regional government in the future has to be a strengthening of local government rather than the threat that local people have so far perceived regional government to be. We have an initiative in the north of England called the Northern Way which the Deputy Prime Minister, John Prescott, is pursuing and which is typical of the way the Government now deal with regional policy. It is all top down. The only way in which local authorities, for example, are involved is by being called to occasional conferences to be told what is happening. There is no consultation, no involvement and absolutely no democracy.
	I shall make two brief points. First, let us reinvigorate local government before we look again at regional government, otherwise there will be no chance at all of getting people to agree to it. Secondly, given that these unelected regional assemblies already exist and are now taking on very important powers, particularly in the planning area, and that they will have an increasing influence over regional issues such as regional plans, we have to look hard at their composition and role. It is entirely wrong that one-third of the representation on these bodies is made up of what someone described as "community stakeholders". "Stakeholder" is a word I would not use myself although, with some reluctance, I will quote someone else using it because it sums up everything that is wrong with new Labour's approach to community government.
	I do not object to these organisations being involved but they have no democratic mandate—even if it is a secondary mandate through councillors being indirectly appointed to the bodies—and it is entirely wrong for them to have the powers which they may be given, certainly in planning terms.
	In order to try to give regional assemblies more democratic credibility, I would reorganise them and put all the MPs for each region on to the assembly and give local government an equal number of places and votes to those held by the MPs. If we want to make regional government and regional assemblies genuinely important— and regarded as such by local people and properly reported by the local media—the main tier of elected officials ought to be represented on them.
	Moreover, once we do that, given that MPs are elected to Westminster, if they go back to their regions and take part in decision-making there, we shall see a sort of organic devolution implicit in that. I think that that proposal ought to be taken very seriously indeed.
	Having said that, I thank the noble Lord, Lord Hanningfield, for introducing this interesting debate.

Lord Brooke of Sutton Mandeville: My Lords, it is a privilege to follow the noble Lord, Lord Greaves, whose experience of local government is voluminous. Although in the 1960s I served for 18 months in the London Borough of Camden, in the years when 18 months on Camden Council were worth 18 years elsewhere, I bow my knee to the much greater knowledge of the noble Lord. I have consistently admired his independence in your Lordships' House and, indeed, within his own party. I strongly agree with his remarks about taking decisions at the lowest possible level, and I also strongly agree with him on the sterility of the concept of stakeholders.
	One of the historians in my party said in his chapter on local government that my party's local government policies lost their way for a while in the last half century when they were no longer conceived and guided by those senior members of the party who actually had long experience of local government themselves. The Burkean wisdom of the ages in delegating power downwards was upset by the present Mayor of London in the late 1970s and early 1980s when he put together an alliance of 20 or so major local authorities to challenge the ancient concordat that it was the Treasury's responsibility to set overall national economic policy, but that local government could otherwise have considerable local spending freedom. I fear that centralised control on local government and local government spending was the unfortunate consequence of that breakdown in the concordat.
	It is therefore a profound relief, certainly to me, that my noble friend Lord Hanningfield, whom I have known in the local government context for nearly 20 years, and my noble friend Lady Hanham, who led the Royal Borough so ably as a neighbour to the Cities of London and Westminster which I represented in the other place, should have such salient positions today in the formulation of our party's local government policies. I congratulate my noble friend Lord Hanningfield on the passion with which he spoke last month on the Government's Statement after the referendum result in the north-east, just as I congratulate him on his dual successes today in securing this debate which he then so relevantly opened.
	And the wisdom of the ages remains important. When the Minister, whom your Lordships' House so admires—those are very genuine words—moved on 20 February last year the Second Reading of the Regional Assemblies (Preparations) Bill, his opening speech lasted 21 minutes with no interventions, but his wind-up speech lasted 37 minutes with 17 interventions—and all the more credit to him for that. I did not myself intervene, but he had kindly responded to my remarks about the wisdom of the ages in that debate by saying that:
	"The noble Lord is right: we should learn lessons from the past for when we go in for such changes. In the forthcoming period . . . I hope we will be able to show that we have done that".—[Official Report, 20/2/03; col. 1330.]
	The purpose of tonight's debate is to test how far that is true.
	In the Reader's Digest atlas of the 1970s, a page is devoted to the colour of hair which shows a precise contemporary correlation with how far the Vikings got. At about the same time as that atlas was published, a friend of mine went to live near Cambridge. After he had been there for around 18 months, he found himself at a cocktail party talking to a military looking man who said, "Haven't seen you before. Where are you from?". My chap replied, "We have been here about 18 months, but before that we lived in Somerset for several centuries". "Ah, Royalists, are you?", said the military looking man. "You'll find we're mainly Cromwellians around here". The English are a slow-moving nation.
	Although at least one relevant Minister in the present administration thought that they owed their defeat in the north-east—which I understand is known in Whitehall as "4/11"—to not having moved fast enough, I think that regionalisation by stealth was probably always the Government's best bet. Whether it was or not, it has now saddled us with empowered regional planning boards and regional spatial strategies and, incidentally, with the chaos that now underlies the Government's essay into regional planning policy in relation to the Gambling Bill where top down now rules again. The structure, in the absence of an advance on a wider front through an adverse majority of four to one in the north-east, is inevitably beginning to look like a house of cards, and a pretty ramshackle one at that.
	I realise that regionalism is the Euro-flavour of the decade, but I have always had my doubts since the Commission decided that the heart of London was the richest area in the European Union by the process of dividing the GDP that was created there by the number of residents in the area and ignoring the hundreds of thousands of workers who commute into the capital every day to work. They come in either from the rest of London, the Home Counties or, nowadays, even further afield.
	When we were planning the long route march to normality in Northern Ireland, we always had to secure base camps at each level of that Everest before we could contemplate the next ascent towards the summit. I suppose that the Government have had a similar concept about regionalism, but we are now condemned to shiver on a freezing saddle or a frozen shoulder after the apocalyptic rejection of regional assemblies, and it will be for the party on these Benches to restore the blood circulation to demoralised local government in due course.
	The great Winston Churchill, whose memorial gates were dedicated in the crypt of St Paul's yesterday, was no great enthusiast for local government. He turned down the presidency of the Local Government Board in the Liberal government after 1906 on the grounds that he was not prepared to be cooped up in a soup kitchen with Mr and Mrs Sidney Webb. But he did understand, when he returned to office in 1951, what his government had to change and achieve—like the building of 300,000 houses a year, to give a single example in the area in which we are talking. His first Leader of the House in that Parliament, Captain Harry Crookshank, said in winding-up the first Queen's Speech debate, that most returning governments, roaming the rooms of the departmental Ministries that their predecessors had just deserted, find skeletons in the closets, but in their case they had found them swinging from the chandeliers.
	If on our return to office we are not true to our traditions of trusting the people and restoring authority to well-tried channels of local government, we shall be condemning the local government arena to the sterile fate of the character in Saki, who had to have his 21st birthday three years running because until his mother moved off 35 any other action would have embarrassed her.
	Finally, there is another consideration, which has not been alluded to in any of the speeches so far, that has a wider dimension than local government in tonight's debate. If English regional government is going nowhere, what is the new answer to the West Lothian question? We shall not even have a fig-leaf to match the precision of one of my favourite military heroes, the Scots private in a military hospital in Iraq in the First World War who, when asked by a visiting general the ambiguous question as to where he had been wounded, replied that he had been wounded three miles the Ardnamurchan side of Baghdad. He gave a precise answer to an ambiguous question. By comparison, time is slowly and silently running out on any answers at all to the precise question that Tam Dalyell posed a quarter of a century ago, and that silence is in due course bound to have repercussions for this Government at the United Kingdom level.

Baroness Scott of Needham Market: My Lords, I thank the noble Lord, Lord Hanningfield, for securing the debate today and for so ably introducing the topic. I also thank all other noble Lords who have contributed. The noble Lord and I are both county councillors from the East of England. We are both passionately committed to local government, but at that point, agreement between us would probably stop. I am sure that he is mightily relieved that after the wilderness years of the last government in which powers were dragged away from local authorities to the centre, that his party has now seen the light and undergone a Damascene conversion. I am touched by the faith that he and the noble Lord, Lord Brooke, demonstrate in their party's change of heart.
	A friend of mine recently showed me his very first election address. As a rather gawky 21 year-old he stood as a Liberal candidate in the first 1974 general election for a seat in the north-west. He showed me his election address and there was his commitment to fight for regional government for the north-west. I was rather pleased to hear some more of the historical context for this debate from my noble friend Lord Rodgers of Quarry Bank. It makes me reflect on why Liberal Democrats and their predecessor parties have always had such a passionate commitment to regionalism. To my mind there are three elements that are related but can be separated out.
	First, as we heard from my noble friend Lord Rodgers, there is the question of regional disparity with regard to housing costs, labour markets, transport links, health outcomes, poverty and so forth and his remarks demonstrate how many years of the centralising policies that characterised successive governments in this country have created this situation. We passionately believe that devolving decisions down to the regions in question would help to break this vicious circle. In some areas, policy-making which can work with the grain of regional diversity instead of trying to create a national one-size-fits-all policy would be hugely helpful.
	The second element is to determine whether services that are currently delivered nationally would be more effective and efficient if they were delivered regionally. In certain areas we believe that the answer is an emphatic "yes"—they would be better delivered regionally. To use transport as an example, there is a growing feeling among many providers and academics in the transport field that we would be better served if transport were looked at regionally in terms of major projects and investments with councils dealing with smaller-scale items. As an example, within the rail industry a national perspective would inevitably lead to the dominance of the south-east commuter markets over all the other regions, to their detriment. Devolving transport expenditure to the regions would allow them to make priorities according to their own needs.
	Thirdly, a need for regionalism arises because there are areas in which it makes sense for regions or sub-regions to act as strategic co-ordinators of local policy. In the case of inward investment, for example, does it really make sense for a lot of local councils individually to be spending money on poaching business from the council next door when by co-ordinating their efforts genuinely new investment could be created? A lot of valuable work is going on at regional level in developing links with foreign investors. It helps to break down the tendency that investors have to look no further than London and the south-east.
	Local councils working together can create a critical mass. Just this week, we have seen what councils working together in the South East England Regional Assembly have been able to do in terms of reducing the housing figure imposed on them by central government—or at least challenging it.
	The noble Baroness, Lady Byford, is the champion of power to local government. On these Benches, so are we, but that does not stop us recognising that certain decisions are not best made by local councils alone. Even the noble Baroness has recognised that in the case of strategic planning, for example, local authorities need to be working together. Sometimes, even a county council is not sufficiently large to do that. She was rather dismissive of strategic planning as an issue, but it does not come much more important than housing, roads, water supplies and all the things that make up strategic planning.
	Even if we were to agree on the factors that point in the direction of regionalism, there may not be agreement between us on how best regionalism could be set up to deliver it. At one end of the spectrum one could have directly elected regional assemblies with tax-raising powers, like mini-parliaments. We could have indirectly elected bodies, co-operative arrangements or decentralisation and the creation of quangos. There is a lot of nuance running through all that.
	As the noble Lord, Lord Brooke, said, for the English regions there is no real history of devolution, and there is no English equivalent to Scottish and Welsh nationalism except perhaps in Cornwall. English regions will be of use and will command public support only if they are substantial and have real powers that can demonstrate proper value to the citizens. It is rather ironic that it was the creation by a Conservative government of regional government offices which opened this whole Pandora's box. I accept that at the time they meant nothing really beyond the disbursement of central administration. It was not devolution in any sense and it barely qualified as decentralising. Nevertheless, it was a significant step in establishing current regional boundaries and moving in a direction of travel towards regionalism. I do not believe that they can absolve themselves of responsibility for that.
	The incoming Labour Government, to give them credit, recognised the need for greater regional economic development and created the regional development agencies. Those bodies have done some valuable work and have significant budgets: by 2008, their combined budgets are due to rise to £2.6 billion. The problem is that they are still creatures of central government, by and large—their funding and targets are set by central government, and they are only marginally linked to the voluntary regional assemblies, which face the task of attempting to link their economic development strategies with the much wider social and environmental objectives, which the local authorities working in the assemblies have to face.
	The whole picture is further muddied by the vast number of quangos responsible for investment in a range of areas, from housing to pollution and from theatres to European grants. Yet it is the voluntary regional assemblies, with no real powers or budgets, which have the sole link to the electorate, by virtue of being composed of elected councillors. The fact that they are not on any real statutory footing means that when the Government need a statutory body, such as the regional housing boards, they have to create a new one from scratch rather than use the assemblies. The only exception has been planning, when the Secretary of State can decide that a regional assembly can assume statutory planning powers. So the one real power given to the regional assemblies has been filched from local government and not passed down from central government.
	It is no wonder that people are baffled. What is so amazing is that the current regional morass is not the result of an accumulation of historic factors but has been created in something less than a decade. It is no wonder that people in the north-east felt unable to vote for the weak assembly that was on offer to them, particularly when their choice was muddled by an enforced local government reform. It is very sad that the Government pressed ahead with those proposals despite a clear warning from noble Lords on these Benches and others that building a convincing campaign with such a poor regional vision would be nigh-on impossible. Indeed, some Liberal Democrats, such as my noble friend Lord Greaves, found themselves unable to support the chosen form of assembly because it was such a pale imitation of regional government as we understand and believe in it.
	All the evidence is that public interest in political institutions is directly linked to the powers that they are perceived to have. That is why turnout in parliamentary elections is higher than in others. As it is, the prospect of directly elected regional government has now faded into the far distant future, leaving behind a morass of regional arrangements that fail the basic tests of accountability and transparency. Our party is currently reviewing all aspects of the regional agenda to see how joint working between central and local government, between quangos and the private sector, can best be achieved. It may be that there is a role for Members of Parliament—even, goodness knows, a role for Members of your Lordships' House—in a reformed system.
	We agree with the Conservative Benches that the role of local government should be strengthened—but, unlike them, we have always believed that to be the case. But it is still wrong to assume that all functions can be carried out at a local level. Some sit very comfortably at an intermediate regional level. It is all very well for the noble Lord, Lord Hanningfield, to refer to Essex but, as we have heard, it is a huge county. Very few local authorities can match it for strategic capability and they cannot be judged against it.
	We accept, with sadness, that the prospect of directly elected regional assemblies has faded into the distant future. We hope that as we move on the Government will avoid a one-size-fits-all policy and that they will reflect the variable needs and demands across the country. Future policy should build on existing voluntary arrangements and seek to strengthen, not diminish, local government. All decision-making should be based on structures that are transparent and in some way democratically accountable. Within those parameters, on these Benches we shall work towards a sustainable framework of regional and local government in future.
	I notice, with regret, that there is not a single Labour Back-Bench speaker present at this debate. The Government must resolve their own internal dilemma on this question. Surrendering the levers of power once they have their hands on them is a difficult thing for any government to do, but partial reforms in that direction, hedged with caveats, apologetically put to the public, have resulted in the mess that we have now. I urge them either to leave things alone or to have the courage of their convictions and do the job properly.

Baroness Hanham: My Lords, I thank my noble friend Lord Hanningfield for leading this important debate. It has not aroused the greatest attention of the Members of this House. It has aroused no attention at all on the Minister's Benches, as the noble Baroness, Lady Scott of Needham Market, pointed out, but it has flushed out one or two extremely thoughtful and helpful speeches.
	I should also like to thank very much the noble Lords on my Benches who supported us today. The noble Baroness, Lady Byford, has plenty to do without joining in on an issue such as this. She carries in her experience a great deal of knowledge about rural life, which becomes extremely important in terms of local government and who administers it. It is not the first time that she has drawn attention to the issue of "small extensions" to villages. I am sure that we will keep returning to that issue. I think that the issue of post offices also will be in everyone's mind for some time, particularly as it is very relevant at the moment.
	My noble friend Lord Brooke has saved me having to declare my interest as a sitting local government councillor. I thank him for his kind comments and also for one of his unique contributions. One of the great pleasures of this House is to listen to people such as my noble friend, who brings not only erudition but humour and great common sense to our debate. He raised in his contribution a problem that, as things stand, will never go away—the West Lothian question.
	Most of the speeches have drawn attention to the unacceptable aftermath of the Government's frolic into referendum campaigns for elected assemblies. The defeats from which the Government suffered—having to abandon two of their chosen regions because of an evident lack of support and confidence in the delivery of the electoral system, and the subsequent rejection by a substantial majority of the electorate in the north-east of the proposition—have left this policy initiative in tatters. Mercifully, however, it has left England intact, something for which I think we are all heartily grateful.
	I was extremely interested in the historical recollections of the noble Lord, Lord Rodgers. Most of us probably did not know or appreciate what he told us—that, originally, he was at the heart of all this. The base of regionalisation was certainly not, as the noble Baroness, Lady Scott of Needham Market, maintained, the Conservatives' move into Government Offices. That was a move to pull together administration in order to make it more efficient, not to make a political contribution to our system.
	As a number of speakers said, the results of the referendum have also left unanswered questions about the proper tiers of government and diverted attention from the insidious transfer of decision-making to regionally based quangos.
	Since 1997, each piece of legislation from the Office of the Deputy Prime Minister, and there has been plenty, has created ever more regional bodies—regional development agencies, regional chambers, planning boards, housing boards, fire and rescue authorities—all of which have a powerful role in deciding the strategy associated with their particular remit, and those are just the ones associated with the Minister's own department. As my noble friend Lord Hanningfield said, there are innumerable other bodies, spawned from other ministries including the important learning and skills councils.
	Regions are a cuckoo in the nest of local government, as is their strategic role which overrides elected local government at other tiers. The regions include counties, cities, towns, villages and parishes, all of which already have democratically accountable local government and have competing interests and concerns. The decision by the electorate in the north-east and the manifest lack of interest in regional government in the other two putative but abandoned election areas should have caused the Government to reel back their enthusiasm for regionalism and reconsider whether there was indeed any future for it.
	For years, this country's—and I suppose that for today's purposes I must speak only of England—elected local government has been based on historic county and metropolitan areas, districts, boroughs and parishes. They are recognised accountable entities with accepted roles, responsibilities and powers. So should the Government not now be considering, as indeed has been alluded to by my noble friend Lady Byford, how they can reinvigorate them as the true representatives and voices of local communities?
	Had it not been for the efforts of this House, counties would have been stripped not only of their planning responsibilities, but of having any role at all in the future planning of their areas. It was not only these Benches, it was the Liberal Democrat Benches as well; but between us we managed to draw some common sense into that situation.
	Heaven knows, little enough is now left to counties but an input into the strategic plans. The Government's sustainable communities plan and Kate Barker's report on housing envisage proposals for huge increases in housing, mostly across the south-east but affecting the northern parts of the country as well. Indeed her report recommended that regional strategic planning and housing boards should be combined, creating a mammoth of unelected power. It is our view that decisions about matters as important as these should not be taken at either national or regional level, but by elected local government. Education, planning, and housing are matters either for individual local authorities, or for a combination of one or two working in partnership. It will be instructive to see what the Government's response is to the South East England Development Agency's response to the insistence that 750,000 houses should be built in the south-east. It has rejected that number and told the Government that it will not build that many. It will be interesting to see who wins that titanic battle.
	Local government powers have been consistently eroded while their reliance upon the beneficence of central government has increased. The standards of their services are constantly under review or inspection by a myriad of outside bodies and their structures are dictated by local government Acts. The Government do not welcome variability or variety in local authorities' performance, seeking to ensure that each is as good as or similar to the other. But doing that creates a situation where local authorities' accountability is to the centre, rather than to the local electorate who might find more enthusiasm for supporting or rejecting the standards that they attained if there were more room for creativity and flexibility.
	The Office of the Deputy Prime Minister has had a fine couple of years with legislation, but is now apparently, exhausted or has run out of prime ministerial credibility, for this is a fallow year. I do not complain about that, but believe that with this enforced leisure, it is time that the Government started to think, not what they could do to tie local government up in knots, but what they could do to release it from the Gordian chains.
	So what do the Government propose for the future, a question that every speaker has asked? What is their response to the rebuttal by the electorate in the north-east, other than the Deputy Prime Minister's reply to do nothing at all? How do they intend to strengthen the role of democratically elected local government, which currently exists, rather than messing around with new untried structures, which have neither the virtue of consistency nor acceptability nor accountability.
	The Government should dismantle the whole regional edifice, give back the quangos' responsibilities to local authorities, create a clear distinction between the powers and responsibilities of central and local government and decentralise to historic local government. Such policies might just breathe new life into local democracy, rather than suffocate it with more bureaucracy and targets.
	The policy of electing some regions and not others was never going to work. It was incomprehensible and unfocused. Either the Government should have had the courage of their convictions and proposed comprehensive regional government across the country or they should have left it alone. We would have disagreed with that. We would have argued against it. But at least it would have been a coherent policy. We should address the real problem, that the Government have created a spider's web of unaccountable bodies in regions, and restore their responsibilities to the elected local government.
	I do not doubt that the Government regret that they ever embarked on their ill-advised journey into regional government, but by doing so they have neither strengthened nor enhanced democratic local government. They have left a fund of unanswered questions.

Lord Rooker: My Lords, there will not be many answers tonight. I shall start as I mean to carry on. I have come to your Lordships' House to answer the issue on the Order Paper, that is, to draw attention to the current status of the regional agencies and bodies, and to the case for returning their responsibilities to elected local government. From my point of view, there is no useful purpose in trawling over the matter that has permeated virtually all noble Lords' speeches, that is, the referendum on 4 November. We said, "Let the people decide". An offer was on the table and they rejected it substantially, by 4 to 1. That has put the issue to bed for a long time, maybe for most of our political lives. We must face the situation as we find it and I do not want to spend any more time on it. I made the position quite clear during the passage of the Bill. I was a bit worried about the quotes from debates on the Bill last year that the noble Lord, Lord Brooke, was going to use, but nevertheless, I can live with what he said tonight.
	Do not get me wrong. I am not knocking the speeches that have been made. It has been very useful and there are some key issues to be raised, notwithstanding the long-term answer to the West Lothian question. There is no doubt about that. But I was not sure that it is the policy of the Conservative Party to abolish the Scottish Parliament. It is obviously not in favour of regional governments so I do not know what its answer to the West Lothian question is. We did not hear anything about that, so I am not going down that road either.
	I declare an interest as I have never been a councillor but I remember that when I was a child in Birmingham the council ran the bank, the buses, the water and the police. All those responsibilities were removed to regional bodies by Tory governments. There were regional planning bodies long before we came on the scene. I understand that the substance of regional planning bodies started in 1962. I believe that they were called regional planning conferences. So this has not happened overnight. But I do not want to make any cheaper points than that. This did not all happen in the past few years. There have been changes going on. But there are some very important issues to address for the future of local government, notwithstanding the great largesse of government funding that will be announced for its operations tomorrow. But we will wait until we hear the Statement.
	However, I sincerely thank the noble Lord, Lord Hanningfield, for securing this debate as it is useful to get these points on the record, if only the point that we do not need to have any more debates about the north-east referendum in the future.
	I want to set out the Government's views on the current status of the regional agencies and bodies and why we need them—that is certainly our view—and what they have achieved. I think that it has been accepted that everything cannot be done by local government. That was touched on in a few speeches but I do not want to make points about individual speeches. People live, work and learn across local government boundaries and there are some issues that transcend local government boundaries as we know them at district council and county council level. We need to make sure that things are joined up. The role of local government is important in working towards better standards of living across the country but its role is different from that of regional agencies. There is no question about that.
	I want to touch on our agenda for local government because we have made some announcements in the past few months that have not generally been taken up in the House but which are, nevertheless, on the record. I do not want to get into a row about this, but our argument is that the regional institutions have not generally taken powers and responsibilities away from local government, although I accept that they did take some on the borders of planning and housing. So I say to the noble Lord, Lord Hanningfield, that there is little scope for returning to local government responsibilities that are operated by the regional agencies because the vast majority of regional agencies have their responsibilities, and, in some cases, powers, from central government as it is currently set up. Our intention is that the regional agencies and local government will complement rather than duplicate each other and will provide effective government at sub-national level.
	It has already been pointed out that the Government Offices were set up for administrative purposes—and I agree—in 1994. In 2002, we set out the position in the English regions, outside London, in the famous White Paper, Your Region, Your Choice: Revitalising the English Regions. We have developed and strengthened the role of the Government Offices. They now cover the responsibilities of 10 government departments in the regions, when originally it was three or four. So there has been a substantial change in that respect. They deliver the responsibilities of central government departments in the regions and work as a team.
	The Government Offices also work with partners to align national, regional and local priorities for investment decisions so that decisions can be made out of Whitehall, nearer to where they will have effect. There is also the question of managing local relationships at a local level on behalf of central government. So the Government Offices perform a valuable role.
	On my fairly infrequent visits to Government Offices, I have noticed that their finger is on the button of what is happening locally in the region, which I pick up from other visits. They raise issues; they are all briefed and know exactly what is going on. It is very useful for central government to have this body out in the regions. So there is a regional knowledge that comes back to the centre to inform the development of policy at the centre.
	In addition, we wanted to create an economic powerhouse for each region. That is why the regional development agencies were set up separately in 1998. Their budgets are large enough for them to make a difference. By 2007–08, their budget will be about £2.3 billion. For the first time in our political lifetime, bodies in the regions are developing a regional economic strategy for each region. We have inherited those regions—we have not looked at regional boundaries. We all have our own views on that; it is not currently an issue but can be considered in the future.
	The regional development agencies across England—including the London Development Agency, which operates slightly differently but is nevertheless part of the family—have, over the past couple of years, created, saved or enhanced some 160,000 jobs and are playing a major role in reshaping the regional economies. We want to be in a position, in a fairly short time, where people are not disadvantaged by where they live. We must look at regional disparities to see what we can do at a regional level. Major disparities among the regions mean that we do not perform anywhere near as well as we should compared with our economic competitors, our partners in Europe. We can do a lot better than we are doing at present.
	More than one speaker has mentioned housing. Whether we are talking about housing for key workers, families or vulnerable people, I take no pleasure in what is implied in supporting lower planning numbers for housing, because, in a way, it means less housing for local people. People would be driven away from the villages and market towns where they were raised; there would be no places for young children; people would be driven away to take up education or look for jobs; families would split up and caring relationships would break down. All kinds of issues would be raised if there were not enough affordable housing, of all ranges, for key workers and for vulnerable, local and young people.
	The issue has to be solved. It cannot always be done at local authority level. I do not want to start another debate, but local authorities have failed to use their powers to create enough sites for travellers. Those local authorities will not take these politically dodgy decisions. They would rather the Government said, "You have to do this". The local authorities can then say to their electorate, "We have to do this; central government have changed the law". That is an abdication of responsibility. If local government want responsibility and accountability, they have to take some hard decisions on occasion. That is just one example.
	Our view is that not all the housing challenges in an area can be addressed by one local authority or solved within one council's area. We saw the need, a couple of years ago, to create a strategic approach. That led to setting up the regional housing boards. Where the homes should go, whether it is social housing, private, or a mixture of tenures, cannot be taken in isolation. Building on the opportunities presented by the strength and experience of regional institutions, we can have integration of the different processes. We have embraced the idea of merging the regional housing board with the relevant regional planning body, as recommended by Kate Barker. We have said that we will not come back in detail on the Barker review until towards the end of next year; we said that we needed 18 months. If the election was 2006, we would have pronounced on Barker. It has nothing to do with an election cycle; we said that we needed 18 months. We accepted the recommendation to merge the regional planning body and the regional housing board. It is well known that the consultation on that finished yesterday, 30 November, and we are starting to consider the responses.
	For regional development and regional economic prosperity we need skills in the workforce. We have massive disparities in the skills of the workforce, as shown up by the census. Joining up the regional economic strategies of the regional development agencies, we can also introduce regional strategies for employment and skills; we must marry the two. It cannot be done at national level, and it is certainly not something that can be done at local authority level. We are going to up-skill the workforce in our regions so that we can perform better. We have also introduced regional directors to the Learning and Skills Council so that it can contribute fully at a regional level and engage directly as a key member of the regional skills partnership.
	There has been a lot of criticism in your Lordships' House of the voluntary regional assemblies. To be effective, regional approaches need to be co-ordinated, and different regional bodies need to be scrutinised. That is one of the reasons why we offered elected scrutiny, but that is on the back burner now. There are other ways of scrutinising. To do this, we have recognised the voluntary regional assemblies in each region.
	These are composed, as has been said and criticised, of representatives from local government, business, trades unions and the wider community. All parties are represented on them, and some are even chaired by Conservative councillors, who are doing a good job. There is no argument about that; they are taking their role extremely seriously. These voluntary assemblies scrutinise the work of the regional development agencies. They are the regional planning bodies, and they will become the regional housing bodies. They play a co-ordinating, strategic role with the full involvement of local authorities and other representatives of the regions.
	All the wisdom does not reside in any one body, which is why we need—I know that there has been resentment of the word "stakeholders", and if you like I will not call them that—the other bodies that represent the community, whether it be business, trades unions, the voluntary sector, or the work of business in the community. All those need to be fully reflected in the strategic decisions co-ordinated at regional level. We see no difficulty about that whatever. They are playing a full, responsive, co-operative and positive role, which we want to build on. The presence of local councillors provides a degree of democratic accountability. No-one is saying that they are fully democratic. We are not making that claim in the first place; but we want them to be a microcosm of the region, to ensure that local authorities and regional bodies work together.
	There are many operations of the Office of the Deputy Prime Minister where we have introduced schemes such as the Housing Market Renewal Pathfinders, for example. They cover nine areas of the country where we need to get a grip on the collapse of the housing market. Every one of them covers more than one local authority; either two, three, four, or in one case five local authorities. They are working well together across the boundaries, and not with big bureaucracies either. I was in south Yorkshire the other day, which covers four authorities. The central team is only 14 people, and the work is being done by local authorities.
	Fire and rescue services are another example of where co-operation at a regional level will deliver better results. We are encouraging local fire and rescue authorities to work more closely together through regional management boards. That will be to everyone's advantage. We are using the integrated fire risk management plans for local authorities to decide their own priorities.
	As I explained at the outset, the successful regional institutions need not and have not taken away powers from local government. On the contrary, we want to complement their decisions. For example, we have done many things to encourage local government. We have repealed restrictive controls on local authority borrowing. That was done through your Lordships' House through the legislation. We have given local authorities greater power to promote the well-being of their communities. We have given them freedom and flexibility to deliver better services more in tune with their local priorities. Higher performing authorities—the excellent authorities—are benefiting from an extended package of freedoms with virtually no ring-fencing, plans or inspection. Moreover, we are committed to continuing the devolutionary agenda, as evidenced by the launch in July of our document, Local:Vision. It carries out an extensive consultation about the future of local government, looking at the options for enabling more decisions to be made in local communities.
	Over the next six months, we will take that debate forward in a series of daughter documents. The first of them was a prospectus for local area agreements, a radical idea for streamlining all the funding that we can get from Whitehall into local areas. Twenty-one local authorities will be used for a year, with publications all around the country; there is more than one in each of the regions. We want to see what we can do with the central government pot. Some areas are excepted—"Supporting People" and some education matters—but much of the central government pot in those areas will be divided up within the local strategic partnership area so that funding priorities can be changed to reflect local circumstances. If successful, we will roll it out in years to come.
	Other key decisions and issues such as neighbourhood management, local leadership and the performance framework will be discussed in more detail. We will produce documents on those.
	The Government remain committed to improving economic performance and quality of life across the country at every level. It does not require elected regional assemblies to do that; that was an opportunity, but it would never have been all-in-one in any event, as we accepted. That does not alter the fact that many of the key decisions at sub-national level need to be made at regional level. That does not take away the powers of local government, which gets enhanced powers from central government in some of the examples that I have given. We will continue local government reform and an active regional policy.
	If we say, "As the model is today, can it continue for the next 10 or 15 years?", I suspect that the answer is no. However, there are degrees of consultation through which we want to go with our colleagues in local government and both Houses to find answers to some of the questions, and to get more decisions locally. We need to provide better value for money, and will seek to do that through opportunities in local government and local councils, working across the boundaries. The boundaries are there for reasons that we all understand; nevertheless, people do not necessarily live, work or have care arrangements fixed within them.
	Some issues were raised, but they were nearly all relevant to the referendum. As I said, I did not really want to debate all that. I am not embarrassed about it—we can debate it till the cows come home—but it does not get us anywhere. We will not have elected regional assemblies; the idea has been put on the back burner, probably for many years to come. We have no plans to resurrect it. We need to have a look at the effect on local government, get more decisions made locally, and enhance the role, where necessary, of regional agencies so that they can perform better. Then we can encourage the voluntary regional assemblies, in particular, to carry out roles of scrutiny. They are fully able and equipped, intellectually and financially, with the capacity to do that. I see no problem with that. Simply because they are not directly elected does not mean that they cannot have a role.
	To involve the wider community beyond local government is very important, whether it is through local strategic partnerships or regional assemblies, so that people can bring something positive to the table. We get better decisions, a better framework, and better delivery of services to our fellow citizens. After all, that is what it is all about.

Lord Hanningfield: My Lords, I thank everyone who participated in the debate. It was very interesting, with many useful contributions. However, I am disappointed that the Minister could not give us a few more answers. It was very telling that he said that things cannot stay as they are and that, in 10 or 15 years' time, things will have to be rather different. He did not tell us what the answers might be, and he said that there will be a lot of confrontation. One thing that disappoints me is that in this country we seem to be obsessed about governments reorganising local government. Instead of getting on and providing services, local government continues to be in turmoil. Other countries do not do that.
	I thank all noble Lords very much. It has been a fascinating debate. We do not have all the answers that we want, and I am sure that we shall revisit the issue in due course. With that, I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.
	House adjourned at fourteen minutes past seven o'clock.